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RC201 .2  L1 7  1 91 1      Syphilis :  its  diagn 


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SYPHILIS 

ITS   DIAGNOSIS  AND  TREATMENT 


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SYPHILIS 

ITS  DIAGNOSIS  AND  TREATMENT 


F.  J.  LAMBKIN,  Col.  R.A.M.C. 

yyy 

LECTURER   ON    SY^HILOLOGY,   ROYAL   ARMY   MEDICAL  COLLEGE,    LONDON 
LATE   SPECIALIST   AT   THE   ARMY    HEADQUARTERS,   INDIA,    ETC. 


WITH   PREFACE  BY 

SIR  FREDERICK  TREVES,  Bart.,  G.C.V.O.,  C.B.,  LL.D. 


NEW    YORK 

WILLIAM     WOOD     &     COMPANY 

MDCCCCXI 


I 


V. 


>^ 


PREFACE 


PROBABLY   no   isolated   disease  has    been  the  subject  of 
so  extensive  and  contradictory  a  literature  as  syphilis. 

The  prevalence  of  the  malady,  the  distressing  symptoms 
with  which  it  is  associated,  and  the  lamentable  results  to 
which  it  may  lead  in  its  later  stages,  serve  to  explain 
the  attention  it  has  received  from  surgical  writers. 

A  review  of  the  literature  of  the  subject  reveals  the 
circumstance  that  it  is  upon  the  question  of  the  treat- 
ment of  the  disease  that  the  most  copious  dissertations 
have  been  bestowed.  There  is  hardly  a  drug  known 
to  medicine  that  has  not,  at  some  time  or  another,  been 
advocated  as  effective  in  the  management  of  this 
complaint. 

At  an  early  period  one  fact  arose  into  prominence 
out  of  the  chaotic  mass  of  dicta  with  which  the  treat- 
ment of  syphilis  was  confounded — the  fact  that  mercury 
had  a  beneficial  effect  upon  the  disease.  This  conviction, 
carried  into  practice,  led  to  some  extravagance  of  action. 
There  soon  came  to  be  recorded  two  periods  of  extremes 
in  the  use  of  the  drug.  At  one  period  mercury  was 
administered  in  amounts  so  large  as  to  deliberately 
produce  the  phenomena  of  mercurial  poisoning  ;  at  the 
•St  other  period  the  employment  of  the  drug  was  condemned, 
not  only  on  the  ground  that  it  was  useless,  but  on  the 
belief  that  it  caused  some  of  the  grosser  lesions  with 
which  the  late  stages  of  the  complaint  were  associated. 


.  - 


vi  PREFACE 

There  are  reasons  to  believe  that  a  sound  mean  has 
now  been  reached  between  these  two  diametrically  opposed 
positions.  While  no  one  would  claim  that  an  infallible 
or  perfect  method  of  treating  syphilis  has  been  arrived 
at,  it  must  at  least  be  owned  that  a  course  of  treatment 
has  been  evolved  which  gives  better  results  than  have 
hitherto  been  attained,  and  which  is  attended  with  but 
few  drawbacks  or  objections. 

In  the  treatment  of  syphilis  by  the  intramuscular  method 
Colonel  Lambkin's  name  has  for  long  been  conspicuously 
associated.  His  opportunities  for  studying  and  treating 
the  disease  have  been  probably  unique,  for  he  has  been 
engaged  for  a  considerable  period  in  the  treatment  of 
syphilis  in  the  army,  both  in  England  and  in  India, 
and  has,  for  some  years  past,  been  in  charge  of  the  chief 
military  hospital  devoted  exclusively  to  venereal  affections. 
He  has  worked  patiently,  cautiously,  and  with  circum- 
spection. 

The  army  affords  an  unequalled  opportunity  for  esti- 
mating the  value  of  any  measure  of  treatment  directed 
against  the  disease.  Syphilis  is  unfortunately  common 
among  soldiers,  while  the  treatment  advised  can  be 
carried  out  systematically  and  continuously,  and  the 
patient  can  be  watched  from  the  time  the  disease  is 
recognised  until  he  ultimately  leaves  the  service. 

Colonel  Lambkin's  experience  has  been  so  exceptional 
that  it  may  be  claimed  for  him  that  in  a  department  of 
practice  to  which  he  has  devoted  the  best  years  of  his 
life  he  speaks  with  an  authority  which  cannot  be  lightly 
put  aside. 

Frederick  Treves. 

July,  1910. 


CONTENTS 


I.  HISTORY     .... 

II.  PATHOLOGY 

III.  CLINICAL  COURSE  :   CHANCRE 

IV.  DIAGNOSIS  AND   PROGNOSIS 
V.  TREATMENT   OF   CHANCRE 

VI.  SECONDARY   PERIOD 

VII.  TERTIARY   SYPHILIS  . 

VIII.  AFFECTIONS   OF   THE    NERVOUS   SYSTEM 

IX.  PARASYPHILIS   OR   QUATERNARY   SYPHILIS 

X.  THE   GENERAL   TREATMENT   OF   SYPHILIS 

XI.  TREATMENT      OF      SYPHILIS     {continued) — IN- 
UNCTION     ...  . 


XII.     TREATMENT     OF     SYPHILIS     {continued) — THE 
INTRAMUSCULAR   METHOD 

XIII.  TECHNIQUE  OF  THE  INTRAMUSCULAR  METHOD 

XIV.  ARYLARSONATE     AND     OTHER     METHODS     OF 

TREATMENT 

XV.     MODERN  AIDS  IN  THE  DIAGNOSIS  OF  SYPHILIS 

INDEX   

vii 


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SYPHILIS 

ITS   DIAGNOSIS   AND   TREATMENT 

CHAPTER     I 

HISTORY 

The  history  of  Syphilis  has  for  the  purpose  of  con- 
sideration been  divided  into :  (i)  its  origin  generally ; 
(2)  whether  its  existence  is  of  prehistoric  antiquity ;  (3)  its 
first  appearance  and  introduction  into  Europe;  (4)  its 
first  appearance  and  introduction  into  England.  As  to 
its  origin,  although  this  is  probably  the  most  interesting 
part  of  the  whole  question,  and  has  formed  the  subject 
for  much  controversy  during  the  last  century,  more  especi- 
ally the  last  decade,  it  cannot  be  said  that  any  definite 
conclusion  has  resulted  therefrom,  other  than  that  it  is 
now  fairly  settled  that  it  has  been  known  to  have  been 
present  in  the  West  Indian  Islands  and  Central  America 
from  time  immemorial ;  but  as  to  the  direct  origin  of  the 
disease  nothing  is  known. 

With  regard  to  its  existence  being  of  prehistoric 
antiquity,  this  question  has  also  been  the  theme  for 
much  discussion,  some  holding  that  evidence  points  to 
an  affirmative  answer  being  given,  whereas  others  deny  it 

1 


2       SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

and  claim  that  it  was  quite  unknown  anywhere  until  the 
close  of  the  fifteenth  century ;  and  even  now  it  cannot  be 
said  that  the  conclusion  which  has  been  arrived  at,  i.e.  that 
the  disease  has  a  prehistoric  existence,  has  been  abso- 
lutely proved.  The  evidence  in  favour  of  the  former  is, 
to  say  the  least,  doubtful,  resting,  as  it  does,  on  writings 
which  speak  of  the  existence  in  prehistoric  times  of 
certain  ailments  which  are  supposed  to  be  descriptions  of 
syphilis,  and  also  on  the  discovery  of  human  bones  bearing 
the  signs  of  syphilitic  lesions.  As  regards  the  writings, 
Hippocrates  describes  ulcers  of  the  mouth  and  genital 
organs,  and  Thucydides  mentions  diseases  of  the  sexual 
organs,  hands,  and  feet  occurring  in  the  plague  of  Athens, 
which  is  supposed  to  have  been  an  epidemic  of  syphilis. 
Lancereaux  believes  the  "  ficus "  of  the  Romans  and 
"sykos"  of  the  Greeks  to  have  been  syphilis. 

From  a  collection  of  medical  writings  made  in  1230  B.C. 
by  the  Emperor  Hoang-ti,  it  would  appear  that  in  those 
far-off  times  the  Chinese  were  fully  acquainted  with 
syphilis,  which  they  treated  with  mercury,  and  that  they 
recognised  the  hereditary  transmission  of  the  disease. 
The  veracity  of  this  statement  has  recently  been  ques- 
tioned by  Okamura,  a  Japanese  writer,  who  maintains 
that,  according  to  the  old  Japanese  and  Chinese  authors, 
syphilis  was  unheard  of  in  either  country  until  the  middle 
of  the  sixteenth  century  of  our  era. 

It  is  asserted  that  syphilis  was  known  in  India  1000  B.C., 
this  assertion  depending  mainly  on  the  descriptions  of 
certain  diseases  taken  from  the  "  Ayurvedas "  of  Susruta, 
which  are  supposed  to  appertain  to  syphilis. 


HISTORY  3 

Syphilis  has  also  been  supposed  to  have  been  known 
to  the  Hebrews  ;  this  is  founded  on  scanty  and  uncertain 
Biblical  quotations,  e.g.  Lev.  xiii.,  which  gives  an  account  of 
leprosy,  but  which  it  is  surmised  was  really  syphilis. 

The  other  evidence  on  which  the  prehistoric  existence 
of  syphilis  is  founded,  i.e.  the  discovery  of  human  bones 
showing  signs  of  syphilitic  lesions,  is,  to  say  the  least,  a 
broken  reed  to  depend  upon,  owing  to  the  paucity  of 
bones  which  have  been  discovered  in  such  a  condition. 
It  would  have  been  expected  that,  if  the  disease  had 
existed  to  any  extent,  innumerable  skeletons  showing 
syphilitic  signs  would  have  been  discovered  in  the  Old 
World.  For  instance,  it  might  be  thought  that  royal 
Rome,  with  all  the  excesses  of  the  Middle  Ages,  would 
have  furnished  plenty  of  evidence  in  this  direction ;  but 
this  has  not  been  the  case. 

The  fact  is  that,  in  spite  of  the  most  painstaking 
research  among  thousands  of  human  skeletons  of  pre- 
historic and  ancient  origin,  there  does  not  exist  one  bone 
showing  unequivocal  signs  of  syphilis.  The  existence 
of  one  bone  in  this  condition,  which  at  the  same  time 
could  be  taken  for  certain  to  be  of  prehistoric  origin,  or 
could  be  at  least  referred  to  a  period  prior  to  1493,  would 
at  once  put  an  end  to  discussion  as  to  the  age  and  origin 
of  the  complaint ;  but  unfortunately  such  is  not  the  case, 
for  it  is  certain  that  no  bone  in  this  condition  is  found 
either  in  German,  English,  or  French  collections  or 
museums. 

As  to  the  question  of  the  antiquity  of  syphilis,  and 
whether  it  existed  in   prehistoric  times,  the  evidence  in 


4        SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

favour  is  of  too  doubtful  a  character  to  enable  a  definite 
conclusion  to  be  come  to  regarding  it ;  at  the  same 
time  it  is  of  a  sufficiently  stable  kind  to  admit  of  the 
probability  of  such  being  the  case. 

The  first  authentic  appearance  of  syphilis  in  European 
countries  dates  between  1493  an^  1500,  which  years  are 
more  or  less  accurately  mapped  out  as  those  which 
saw  the  introduction  of  the  disease.  It  has  been 
proved  beyond  doubt  that  it  was  brought  into  Spain 
by  sailors  of  Columbus  returning  from  Haiti  and  Cen- 
tral America  in  1492,  and  that  it  spread  to  Italy  from 
Spain. 

The  campaign  of  Charles  VIII.  of  France  during 
1494-5,  as  a  result  of  which  many  mercenary  bands, 
accompanied  by  a  great  following  of  women,  collected 
in  Italy,  and  there  got  in  touch  with  each  other,  formed 
the  most  favourable  opportunity  for  the  spread  of  the 
disease  ;  and  there  can  no  longer  be  any  doubt  that  the 
latter  first  attracted  attention  in  Europe  when  the  French 
under  Charles  sojourned  in  Italy,  especially  in  Naples — 
hence  the  dates  between  February  and  May  1495.  Critics 
are  unanimous  as  to  this,  and  also  consider  an  invasion 
from  without  as  having  occurred,  for  which  they  blame 
the  Spaniards.  It  is  known  that  after  the  arrival  of 
Columbus  in  Barcelona,  on  his  return  from  America  and 
the  island  of  Haiti  in  1494,  syphilis  spread  there  amongst 
the  inhabitants.  The  following  year  Charles  VIII.  of 
France  began  preparations  for  his  campaign,  and  attracted 
mercenaries  from  neighbouring  countries,  amongst  whom 
were   many  Spaniards   infected    with   syphilis.      Thus   it 


HISTORY  5 

came   about  that   the  disease  spread  during  the  stay  of 
the  French  army  in  Italy. 

Evidence  goes  to  show  that  the  followers  of  Columbus 
first  contracted  the  disease  in  the  island  of  Haiti,  and  in 
Central  America.  According  to  Diaz  de  Isla,  a  learned 
physician  of  Barcelona,  who  himself  witnessed  the  in- 
vasion of  syphilis  in  Spain,  the  disease  had  been  known 
in  Haiti  (Espafiole)  from  time  immemorial,  and  Oviedo 
completely  concurs  in  this  American  origin  of  syphilis, 
and  declares  it  to  be  a  specific  disease  of  the  Antilles 
and  Central  America.  According  to  Oviedo,  syphilis  was 
communicated  by  the  Indian  women  to  the  first  Spaniards 
who  came  there  with  Columbus,  and  brought  by  them 
to  Spain,  whence  it  spread  to  the  army  of  Charles  VIII. 
Amongst  his  informants,  Oviedo  includes  both  those  who 
accompanied  Columbus  upon  his  first  voyage  and  those 
who  were  with  him  on  his  second.  Las  Casas,  a  con- 
temporary physician  of  the  time,  whose  father  was  with 
Columbus  during  the  second  voyage,  and  who  himself 
had  lived  in  Haiti,  testifies  to  the  existence  of  syphilis 
in  the  latter  place  before  the  advent  of  the  Spaniards. 
He  says :  "  I  took  the  trouble  upon  several  occasions 
to  interrogate  the  Indians  as  to  whether  the  disease 
was  of  great  antiquity,  and  they  answered  Yes,  that 
it  dated  from  a  period  long  before  the  arrival  of 
the  Christians,  its  origin  being  beyond  the  memory  of 
man  ;  and  it  is  an  undoubted  fact  that  all  Spaniards 
addicted  to  sexual  excesses,  and  who  did  not  observe 
the  virtue  of  continence,  were  attacked  by  the  disease, 
not  one  in  a  hundred  escaping."     Again,  Oviedo,  in  his 


6       SYPHILIS:   ITS  DIAGNOSIS  AND  TREATMENT 

report  to  the  Emperor  Charles  V.,  says  :  "  Your  Majesty 
may  take  it  for  certain  that  this  disease  has  originated 
in  the  West  Indies,  where  it  is  common  amongst  the 
Indians,  and  in  those  regions  it  is  not  so  dangerous  as 
with  us." 

Thus  the  reports  of  all  these  contemporaries  are 
unanimous  as  to  syphilis  being  of  American  origin,  and 
that  it  was  the  syphilis  of  Haiti  which  eventually  spread 
through  Europe  and  the  Old  World.  Confirmation  of 
these  narratives  of  Diaz  de  Isla,  Oviedo  and  Las  Casas 
concerning  the  origin  of  syphilis  in  Europe,  can  easily 
be  obtained  from  documents  and  chronicles  of  contem- 
porary Spanish  and  Italian  writers,  amongst  whom  was 
Senarega,  who  states  categorically,  in  his  history  of 
Genoa,  that  syphilis  had  appeared  in  Spain  two  years 
before  the  campaign  of  Charles  VI II.,  i.e.  in  1493,  where 
it  had  been  introduced  from  the  Far  West ;  and  the 
contemporary  Italian  physicians  of  the  time  declare  that 
syphilis  came  to  Italy  from  Spain. 

The  conclusions  arrived  at  are:  (1)  That  syphilis  was 
unknown  in  Europe  prior  to  the  year  1493  '■>  (2)  That  its 
home  is  America,  or,  as  far  as  Europe  is  concerned,  the 
island  of  Haiti,  whence  the  crew  of  Columbus  brought 
it  after  the  latter's  first  voyage. 

Introduction  into  England 

Everything  points  to  syphilis  as  having  been  brought 
to  England  by  English  soldiers,  who  were  fighting  in 
Italy  as  mercenaries,  and  returning  home  took  the  disease 
with  them.     All  contemporary  writers  of  the  day  are  very 


HISTORY  7 

explicit  on  this  subject :  the  date  of  this  would  be  the 
end  of  the  fifteenth  century. 

In  Scotland  it  is  first  heard  of  in  1497,  a  decree  being 
published  then  by  James  IV.  ordering  all  persons  suffering 
from  syphilis  to  leave  Edinburgh :  they  were  to  be  taken 
to  an  island  opposite  Leith  and  there  treated. 

The  history  of  syphilis  from  the  above  date  to  1767 
was  one  of  varying  fortune,  doubts  being  cast  upon  the 
identity  of  the  different  venereal  disorders,  until  the  cele- 
brated John  Hunter  made  the  mistake  of  his  illustrious 
career,  an  error  which  was  destined  to  produce  a  period 
of  decay  in  syphilology  that  was  to  last  for  years. 

Hunter's  Mistake 

In  1767  Hunter  inoculated  himself  on  the  prepuce 
with  pus  from  a  purulent  gonorrhea,  which  produced  a 
chancre,  followed  by  constitutional  syphilis,  from  which 
he  concluded  that  the  secretion  of  gonorrhea  was  capable 
of  producing  gonorrhea,  chancre,  and  syphilis,  and  that 
all  three  were  identically  the  same  disease.  He  made 
the  further  mistake  of  stating  that  the  blood  and  secre- 
tions of  syphilitics  were  incapable  of  transmitting  such 
contagion.  It  may  be  imagined  how  these  doctrines  put 
back  the  clock  in  the  advancement  of  the  knowledge  of 
syphilis  ;  there  was  no  progress  until  the  time  of  Ricord 
(1800-89),  who  proved  conclusively,  by  repeated  inocu- 
lations, that  gonorrheal  secretions  pure  and  simple  never 
produced  chancre  or  constitutional  syphilis.  He  further 
came    to   the   following    conclusions   as   regards  syphilis  : 


8       SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

firstly,  that  during  the  primary  stage,  which  consists 
of  the  chancre,  it  was  auto-inoculable,  its  induration  being 
the  expression  of  the  passage  of  the  poison  into  the 
organism ;  secondly,  he  maintained  that  in  its  secondary 
stage  syphilis  is  not  contagious,  but  is  capable  of  trans- 
mission to  the  offspring ;  and  thirdly  he  described  the 
encroachment  of  the  poison  upon  the  bones  and  viscera ; 
during  this,  the  third  stage,  he  said  that  syphilis  is 
neither  contagious  nor  is  it  transmissible  to  the  offspring. 
Ricord  also  differentiated  between  the  hard  and  the  soft 
chancre ;  the  micro-organism  of  the  latter  was  afterwards 
discovered  by  Ducrey  in  1889. 

Undoubtedly  to  Ricord's  teaching  we  owe  the  scientific 
basis  on  which  the  future  study  of  the  disease  was  to 
be  grounded,  and  which  eventually  led  to  the  formation 
of  the  most  important  conclusions  upon  the  nature  and 
cause  of  syphilis.  In  1903  Metchnikoff  and  Roux  made 
the  all-important  discovery,  that  syphilis  is  transmissible 
to  monkeys,  and  in  1895  Schaudinn  discovered  that  the 
origin  of  the  disease  is  due  to  a  protozoon  which  he 
named  the  "  Spirochceta  pallida" 


CHAPTER   II 

PATHOLOGY 

ALL  the  lesions  of  syphilis  consist  of  an  interstitial  in- 
filtration of  embryonic  cells,  constituting  an  inflammatory 
neoplasm,  which  undergoes  resolution  in  the  case  of  the 
chancre  and  secondary  lesions,  but  tends  to  the  formation 
of  fibrous  tissue  in  the  tertiary.  A  syphilitic  neoplasm 
consists  of  both  round  and  giant  cells ;  an  accumulation 
of  these  (which  can  often  be  seen  by  the  naked  eye)  is 
called  a  miliary  gumma,  and  a  collection  of  the  latter  give 
rise  to  gummata,  which  may  attain  to  almost  any  size. 
In  the  tertiary  lesions  a  meshwork  of  fibrous  bands  can 
be  seen  intersecting  the  whole  or  part  of  an  organ,  and  in 
these  meshes  gummata  are  found  of  various  sizes,  appear- 
ing as  yellow  masses  ;  each  gumma  is  surrounded  by  a 
fibrous  capsule,  and  in  some  of  them  the  centre  is  seen 
to  be  undergoing  caseous  degeneration,  which  is  probably 
due  to  either  obliteration  of  vessels,  overcrowding  of  cells, 
or  to  the  direct  action  of  the  syphilitic  poison  itself  on 
the  cells.  This  latter  supposition  is  now  generally 
accepted  as  correct,  and  is  supported  by  Levaditi's  dis- 
covery of  the  Spirochceta  pallida  within  the  paren- 
chymatous cells.     The  changes  caused  by  syphilis  consist 

9 


io      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

of  peri-arteritis,  which  leads  to  obliteration  of  vessels ; 
inflammatory  infiltrations,  tending  to  interstitial  fibrosis ; 
and  certain  results  due  to  the  direct  action  of  the  poison 
on  the  parenchymatous  cells.  Besides  its  direct  action 
on  the  blood  and  cells,  which  produces  the  ordinary 
syphilitic  symptoms,  the  virus  of  syphilis  has  a  toxic 
effect  on  the  cells,  which  leads  to  degenerations  re- 
sulting in  certain  effects  and  sequelae,  to  which  Fournier 
has  given  the  name  of  Parasyphilis,  among  these  being : 
leucoderma,  tabes,  general  paralysis,  epilepsy,  leuco- 
plakia,  various  muscular  atrophies,  diabetes,  Bright's  disease, 
arterio-sclerosis,  various  osseous  lesions,  tuberculosis  and 
epithelioma  ;  add  to  these  an  hereditary  parasyphilitic 
affection  caused  by  the  arrest  of  development — both 
physical  and  mental  malformations,  rickets,  hydrocephalus, 
meningitis,  infantile  general  paralysis,  tabes,  etc. 

Induration 

The  first  lesion  of  syphilis  is  the  indurated  chancre 
which  constitutes  primary  syphilis,  and  the  induration  is 
peculiar  to  it.  As  a  rule  the  chancre  appears  as  a 
superficial  erosion  with  no  definite  borders ;  it  is  usually 
circular  in  form,  dark  red  in  colour,  becoming  greyish  later 
on,  and  exuding  a  thin  sanious  fluid.  Between  the  fifth 
and  tenth  day  after  the  first  appearance  its  edges  begin 
to  harden  ;  this  hardening  or  indurating  process  goes  on 
around  the  original  erosion  up  to  about  the  twenty-fifth 
day,  when  it  ceases,  and  may  then  begin  to  be  absorbed  ; 
it  usually  has  disappeared  at  the  end  of  two  months. 
The  induration  is  not  the  result  of  inflammatory  action, 


PATHOLOGY  n 

as  can  be  seen  by  the  absence  of  pain  or  itching,  but 
it  is  formed  by  a  process  of  small-celled  infiltration  and 
hyperplasia  of  connective  tissue  cells.  Epithelial  and  giant 
cells  are  also  present,  whilst  the  small  arterioles  and  veins 
are  obliterated  by  peri-arteritis  and  endo-phlebitis. 

The  amount  of  induration  varies  in  different  chancres, 
from  slight  hardening  of  the  borders  of  the  lesion,  to  the 
extent  of  forming  a  hard  lump  the  size  of  a  hazel-nut. 

Amount  of  Induration :  what  relation  has  it  to  the 
progress  of  the  disease  ? 

There  is  a  general  idea  that  the  future  of  the  syphilitic 
attack  depends  much  on  the  amount  of  induration  which 
develops  at  the  site  of  the  original  point  of  infection — that 
is,  that  the  greater  the  induration  the  more  severe  will  be 
the  after-symptoms  and  lesions,  and  vice  versa.  My  personal 
experience  shows  that  it  is  not  the  amount  but  the  per- 
sistence, in  spite  of  thorough  treatment,  of  the  induration , 
which  indicates  a  severe  attack. 

BACTERIOLOGY 

The  microbiology  of  syphilis  dates  back  to  a  period 
before  that  of  microbiology  itself.  Before  there  existed 
any  idea  of  the  part  played  by  microbes  in  fermentation, 
it  was  supposed  that  syphilis  was  caused  by  certain 
minute  organisms  and,  twenty  years  before  the  discovery 
of  lactic  acid  fermentation  by  Pasteur,  discussions  were 
frequent  as  to  the  microbiology  of  syphilis. 

When  once  micro-organisms  had  been  discovered  in 
a   whole   heap   of  different    infectious    diseases,   numbers 


12      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

of  bacteriologists  set  to  work  to  search  for  the  supposed 
organism  of  syphilis,  amongst  them  being  Weigert  and 
his  pupil  Lustgarten.  The  latter  discovered  a  bacillus 
in  various  syphilitic  lesions,  which  eventually  was  to  be 
known  as  "  Lustgarten's  bacillus,"  and  which  for  a  time 
was  considered  to  be  intimately  connected  with  the  cause 
of  syphilis,  but  was  subsequently  discarded.  Then  De 
Lisle  thought  that  he  had  discovered  that  syphilis  was 
caused  by  a  certain  large  bacillus,  but  his  theory  could 
not  be  confirmed. 

Search  for  syphilitic  bacteria  having  completely  failed, 
scientists  began  to  believe  that  the  microbe  of  syphilis 
might  be  a  protozoon,  and  soon  Seigel  published  an  essay 
in  which  he  described  his  discovery  of  a  small  protozoon 
in  syphilitic  secretions ;  this  he  believed  to  be  the  real 
organism  of  the  disease,  and  he  named  it  "  Cytoryctes 
luis." 

SpirocJicBta  pallida  was  first  seen  by  Schaudinn  in  some 
papules  round  the  vulva  of  a  woman,  who  was  suffering 
from  a  hard  chancre  in  the  same  region. 

From  further  research  Schaudinn  was  able  to  show  that 
in  the  genital  organs  two  varieties  of  spirilla  are  to  be 
found.  One  of  these  may  be  found  under  both  conditions, 
whereas  the  other  is  only  present  in  syphilitic  lesions. 
The  former  he  called  6".  refringens.  It  is  larger  than 
S.  pallida,  and  its  spiral  turns  are  fewer  and  much 
better  marked ;  it  is  easily  stained  by  any  method, 
especially  by  Giemsa's,  and  is  much  more  intensely  stained 
than  S.  pallida.  The  latter  is  smaller,  more  delicate  in 
appearance,  and  its  spiral  turns  are  more  numerous,  and 


PATHOLOGY  13 

not  so  well  marked  ;  it  stains  with  much  difficulty  by 
any  method.  Schaudinn  and  Hoffmann  were  able  to 
prove  definitely  that  5.  pallida  is  to  be  found  only  in 
syphilitic  affections  ;  further,  that  it  is  to  be  found  not 
only  on  the  surface  of  syphilitic  human  papules  and 
chancres,  but  also  in  the  deep  tissues  of  the  enlarged 
syphilitic  glands.  At  first  these  spirilla  were  only  found 
in  primary  and  secondary  lesions  of  the  genital  organs, 
but  with  improved  technique  they  were  soon  demonstrated 
in  secondary  lesions  far  removed  from  this  region— i.e. 
in  the  blood,  lymph,  lymphatic  vessels  and  glands,  also 
in  the  saliva  and  urine  of  syphilitic  patients ;  and,  finally, 
they  were  found  by  Spitza,  in  1905,  in  gummata,  also 
by  Schaudinn,  who  showed  them  in  the  peripheral  layer 
of  a  gumma  of  the  liver  of  a  syphilitic  child. 

In  the  vascular  system  Reuter  found  these  organisms 
in  sections  of  the  aorta  of  an  old  syphilitic  who  had 
dropped  dead — a  fact  which  was  confirmed  by  Schaudinn. 
Soon  it  became  an  established  fact  that  the  specific 
spirilla  were  to  be  found  in  the  primary,  secondary,  and 
tertiary  lesions  of  syphilis,  but  up  to  the  present  they 
have  not  been  demonstrated  in  those  affections  known  as 
parasyphilitic. 

As  regards  hereditary  syphilis,  the  organisms  were  soon 
found  in  almost  all  the  tissues  of  new-born  children 
affected  with  the  disease,  especially  in  the  liver  and 
in  certain  parts  of  the  skeleton — i.e.  the  periosteum, 
bones,  etc. 

Important  as  was  the  discovery  of  the  5.  pallida,  an 
equally  important  one  was  the  announcement  by  Metchnikoff 


14     SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

and  Roux  in  1903  that  syphilis  is  communicable  to  animals ; 
they  succeeded  in  conveying  the  disease  from  a  human 
syphilitic  to  a  chimpanzee  by  inoculation,  producing  in 
the  latter  a  primary  syphilitic  chancre,  which  was  after- 
wards followed  by  a  secondary  train  of  symptoms.  This 
experiment  they  repeated  over  and  over  again  in  the 
chimpanzee  with  similar  results  ;  but  monkeys  of  the  lower 
kind,  such  as  macaques  and  papion,  did  not  respond  to 
it  so  readily,  syphilis  being  limited  to  a  modified  chancre, 
which  was  not  followed  by  secondaries.  The  chancre 
produced  was  an  cedematous  nodule,  which  was  followed 
by  desquamation,  no  ulceration  taking  place,  nor  was 
induration  or  adenitis  well  marked,  which  points  to  the 
resistance  of  these  lower  animals  to  syphilis.  It  has 
been  established  that  monkeys  are  more  refractory  to 
syphilis  the  farther  they  are  removed  from  the  anthropoid, 
and  that  the  chancre  of  the  macacus  was  really  syphilis. 
Metchnikoff  and  Roux,  by  producing  the  disease  in  a 
chimpanzee  they  inoculated  from  it,  proved  it. 

These  researches  led  to  various  attempts  being  made 
to  prepare  an  antisyphilitic  serum,  but  up  to  the  present 
all  have  failed. 

With  regard  to  the  situation  where  the  organism  is 
Best  found,  my  own  experience  is  that  it  is  easier  to 
demonstrate  it  in  hereditary  lesions  than  in  those  of 
acquired  syphilis,  and  in  early  secondary  rashes  and 
mucous  lesions  than  in  the  chancre  ;  it  is  more  abundant 
in  the  deeper  parts  than  superficially.  Levaditi  states 
that,  although  present  in  the  blood-vessels,  the  Spirochceta 
pallida   is   rarely   found   in   the   blood   itself,  from   which 


PATHOLOGY  15 

fact  it  is  now  generally  believed  that  the  latter  simply 
acts  as  a  conveying  medium,  but  not  as  one  in  which 
the  organism  is  developed. 

EXAMINATION 

for  Spirochseta  pallida 

Search  for  the  Spirochceta  pallida  has  been  rendered 
much  easier  by  the  introduction  of  the  dark  background. 
The  material  should,  when  possible,  be  taken  from  the 
deeper  parts  of  a  lesion,  and  having  done  so,  it  should 
be  placed  on  a  cover-glass,  spread  out,  a  little  normal 
saline  solution  added  to  it,  and  there  and  then  examined 
under  a  -—  in.  immersion  lens  on  a  dark  background. 
The  5.  pallida  is  a  very  delicate,  mobile,  spiral  organism, 
varying  in  length  from  4  to  14  /x  (about  the  size  of  a 
red  corpuscle),  and  about  ^  fi  in  thickness.  It  differs 
from  the  spirochete  with  which  it  is  most  likely  to  be 
confounded  in  that  the  latter  is  generally  found  on  the 
surface  of  lesions,  whereas  the  6\  pallida  inhabits  the 
deeper  parts ;  also  the  *S.  pallida  is  smaller,  is  less 
refractive,  is  harder  to  stain,  has  more  numerous  spiral 
turns,  and  retains  its  spiral  form  both  in  motion  and 
at  rest.  It  stains  pink  with  Giemsa's  stain,  whilst  other 
spirochsetes  stain  blue. 


CHAPTER    III 
CLINICAL   COURSE:   CHANCRE 

Clinical  Course  of  Syphilis 

THE     clinical    course    of    syphilis    is    divided    into    six 
stages  : 

i.  The  stage  of  primary  incubation,  that  between 
exposure  to  infection  and  the  appearance  of  the  chancre. 

2.  The  primary  stage,  during  which  the  chancre  develops 
and  glands  enlarge. 

3.  The  secondary  incubation  stage,  that  between  the 
appearance  of  the  chancre  and  the  stage  of  secondary 
symptoms. 

4.  The  secondary  stage — the  period  during  which  fever, 
neuralgic  pains,  and  syphilis  of  the  skin  appear. 

5.  The  intermediate  stage,  during  which  the  patient 
may  be  practically  free  from  any  signs. 

6.  The  tertiary  stage,  which  is  characterised  by  the 
formation  of  gummata,  periostitis,  osteitis,  etc. 

The  Initial  Lesion 

The  first  lesion  of  syphilis  is  the  chancre,  which  makes 

16 


CLINICAL  COURSE:    CHANCRE  17 

its  appearance  at  the  site  of  inoculation  in  from  twenty- 
five  to  thirty  days  after  exposure ;  this  latter  is  a  fair 
average  time,  and  as  a  rule  it  may  generally  be  sur- 
mised that  a  sore  appearing  after  ten  days  from  the 
date  of  exposure  is  syphilitic. 

The  chancre  is  generally  single,  but  is  very  often 
multiple,  and  there  may  be  as  many  as  six,  seven,  or 
even  more  initial  lesions. 

The  chancre  begins  as  a  small,  sharply-rounded,  ex- 
coriated spot,  the  surface  of  which  is  on  a  level  with 
the  surrounding  parts.  It  looks  exactly  like  an  erosion. 
The  colour  is  dull  red,  and  later  on  may  assume  a  coppery 
hue.  At  first  the  primary  lesion  may  cause  little  or  no 
disturbance,  the  patient's  attention  being  generally  called 
to  it  by  some  itching.  For  the  first  five  or  six  days 
there  is  nothing  very  characteristic  about  it,  but  at  the 
end  of  that  time  induration  may  become  perceptible 
round  its  edges,  and  this  increases  and  may  become  more 
evident  and  pronounced  up  to  the  end  of  two  or  three 
weeks  after  being  first  noticed.  This  induration  is  typical 
of  the  syphilitic  chancre.  As  regards  the  induration, 
stress  must  be  laid  on  the  fact  that  at  first  it  is  not 
present,  and  may  not  become  sharply  defined  until  the 
tenth  day,  which  fact  has  led  to  innumerable  mistakes. 

Induration  is  a  peculiar  hardness  of  the  tissues  around 
and  beneath  the  sore,  and  is  formed  without  any  inflam- 
mation having  taken  place  ;  no  pain,  heat,  or  redness  occurs 
during  its  formation.  It  is  peculiarly  circumscribed,  and 
it  remains  after  the  chancre  has  healed,  and  may  continue 
to  do  so  for  weeks  or  months. 

2 


1 8      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Nature  of  the  Chancre 

A  chancre  is  formed  of  small-celled  infiltration  and 
hyperplasia  of  the  connective  tissue  cells,  which  is  sup- 
ported in  a  meshwork  of  thickened  blood-vessels,  some 
of  the  latter  being  entirely  obliterated  by  sclerosis.  This 
condition  constitutes  induration. 

Chancrous  Erosion 

The  chancrous  erosion  is  by  far  the  most  common  form 
in  which  the  primary  lesion  is  found.  It  is  most  marked 
on  the  inner  side  of  the  prepuce.  In  shape  it  is  commonly 
circular  or  ovoid,  but  sometimes  of  an  irregular  shape.  Its 
floor  is  but  slightly,  if  at  all  excavated  ;  its  surface,  from 
which  a  serous  secretion  oozes,  is  smooth  and  polished  : 
usually  there  is  but  one  such  lesion,  but,  as  already  stated, 
there  may  be  as  many  as  five,  six,  or  seven.  Owing  to  the 
absence  of  induration  in  the  first  stage  of  these  chancres, 
diagnosis  may  be  difficult,  but  the  absence  of  itching  and 
burning,  their  dark  colour  and  chronicity,  their  late  ap- 
pearance after  exposure,  may  help  in  distinguishing  them 
from  herpes,  with  which  they  are  likely  to  be  confused. 

Induration  of  Chancre 

When  the  chancre  remains  superficial  the  induration  is 
spread  out  into  a  disc-like  mass ;  it  is  then  called  the 
"  parchment-like  sore,"  and  is  mostly  found  on  the  integu- 
ment of  the  penis  and  in  the  vulva.  Indurated  chancres 
are  generally  found  in  the  sulcus  coronarius,  near  the 
fraenum.  , 


CLINICAL   COURSE:    CHANCRE  19 

Varieties  of  Chancre 

The  chancre  may  assume  various  shapes,  when  it  is 
called  by  different  names  :  the  dry  papule,  ecthymatous 
chancre,  silvery  spot,  annular  chancre,  and  mixed  chancre. 

Dry  Papule 

The  dry  papule  is  found  mostly  on  the  integument  of 
the  penis  at  the  base  or  pubic  part  As  a  rule  it  is 
solitary,  and  appears,  as  its  name  implies,  as  a  dry,  hard 
papule.    It  is  a  very  characteristic  form  of  the  true  chancre. 

The  Ecthymatous  Chancre 

This  is  simply  a  chancre  which  becomes  covered  with  pus- 
crusts,  and  may  be  developed  from  either  a  dry  papule  or 
a  chancrous  erosion.  It  is  simply  a  chancre  whose  surface 
has  become  irritated,  and  ulceration  has  taken  place,  with 
the  consequent  formation  of  pus. 

The  Annular  Chancre 

The  name  of  "  annular  chancre  "  is  given  to  those  sores 
in  which  the  induration  assumes  a  ring-like  shape,  and  in 
which  the  centre  is  less  thickened  and  infiltrated.  This 
form  of  chancre  is  found  generally  on  the  internal  surface 
of  the  prepuce,  sometimes  on  the  glans,  and  very  often  on 
the  cutaneous  surface  of  the  penis. 

The  Silvery  Spot 

This  was  first  described  by  Taylor,  and  is  a  rare  condition. 
Its  site  is  generally  the  glans  and  about  the  meatus.  At 
first  it  looks  like  a  pin-head  spot  which  had  been  touched 


20     SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

with  carbolic  acid  :  this  lesion  increases  slowly,  and  is 
subsequently  raised  up  well  above  the  surface  by  the 
induration.  It  preserves  the  integrity  of  its  surface  until 
it  reaches  an  area  of  2  mms.,  when  it  disappears,  and  is 
replaced  by  a  smooth,  shiny  surface  on  an  indurated  base. 

Various  other  Chancres 

Besides  the  above  there  are  many  other  chancres  which 
go  by  various  names :  the  inflamed,  phagedenic,  relapsing 
(which  may  be  true  or  false),  and  the  mixed  chancre. 

The  two  former  are  what  their  names  imply. 

The  Mixed  Chancre. 

It  is  possible  for  both  simple  chancre  and  syphilitic 
chancre  to  co-exist  at  the  same  time,  and  either  may 
be  inoculated  on  the  other.  If  the  virus  of  syphilis  be 
inoculated  at  the  same  time  and  at  the  same  spot  as  the 
simple  chancre,  a  hard  sore  will  develop  in  time  at  the 
point  formerly  occupied  by  the  soft  sore.  On  the  other 
hand,  a  soft  sore  may  be  inoculated  on  the  top  of  a 
syphilitic  chancre,  resulting  in  an  ulcerating  sore  situated 
on  an  indurated  base,  thus  constituting  the  mixed  chancre. 
{Seep.  26.) 

Pain  and  Inflammation 

Absence  of  pain  and  inflammation  is  common  to  all 
uncomplicated  chancres,  the  patient's  attention  being 
generally  first  drawn  to  its  presence  by  some  degree  of 
itching  ;  but  even  this  may  be  absent,  and  the  chancre 
fully  developed  before  it  is  noticed. 


CLINICAL   COURSE:    CHANCRE  21 

Recurring  Chancre 

Recurring  chancres  are  of  two  kinds — false  and  true. 

False  Relapsing  Chancre. — The  former  has  generally  been 
described  as  a  fresh  induration  appearing  at,  or  perhaps 
near,  the  site  of  an  old  sore.  This  induration  may  appear 
without  any  apparent  cause  as  to  treatment  or  otherwise  ; 
and  at  almost  any  time,  from  a  few  weeks  to  ten  or  twelve 
years  after  the  healing  of  the  original  chancre.  Usually 
its  surface  remains  intact,  but  may  become  ulcerated,  and 
then  simulate  a  disintegrating  gumma. 

True  Relapsing  Chancre. — Having  entirely  disappeared 
under  treatment,  the  induration  reappears  at  the  site 
of  the  old  sore,  and  assumes  exactly  its  previous  con- 
dition ;  its  surface  may  become  broken,  and  to  all  intents 
and  purposes  the  old  chancre  may  reappear,  to  be  got 
rid  of  again  by  specific  treatment.  This  chancre,  to  the 
writer's  mind,  is  almost  solely  dependent  on  the  line  of 
treatment  which  is  adopted :  should  this  be  dropped  too 
early,  then  the  induration  is  likely  to  reappear,  and  is 
then,  no  doubt,  a  fresh  nucleus  for  the  Spirocluzta  pallida. 

SEATS   OF   CHANCRE 

The  primary  lesion  may  be  seated  on  any  part  of  the 
body  which  may  have  been  exposed  to  infection  ;  hence 
they  occur  more  frequently  on  the  genital  region,  which  is 
the  generally  exposed  part.  Chancres  are  divided  into 
genital  and  extragenital. 


22      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Genital  Chancre 

Two-thirds  of  all  chancres  are  found  on  the  mucous 
membrane  of  the  prepuce  just  behind  the  corona,  or  on  the 
surface  of  the  glans  penis,  but  they  are  found  also  at  the 
urinary  meatus,  within  the  urethra,  at  the  base  of  the  penis, 
scrotum,  groin,  and  anus,  and  these  assume  certain  definite 
characters  according  to  the  sites  occupied  :  thus  chancres 
of  the  surface  of  the  glans  penis  are  generally  flat  at 
first,  becoming  depressed  later  on,  and  surrounded  by  a 
laminated  layer  of  induration  :  chancres  of  the  coronal 
glans  show  a  tendency  to  be  raised  above  the  surface, 
induration  is  well  marked,  extensive,  and  nodular. 

Chancres  of  the  Urinary  Meatus 

In  these  chancres  either  one  or  both  lips  of  the  meatus 
may  be  involved,  but  both  are  generally  affected.  The 
mucous  membrane  is  found  thickened,  and  the  lips  are 
glued  together  by  a  scanty  viscid  discharge.  Induration 
in  these  chancres,  although  limited,  is  well  marked. 
Needless  to  say  that  chancres  of  the  meatus  may  be 
mistaken  for  gonorrheal  ulceration  and  vice  versa,  and 
further  that  a  correct  diagnosis  is  rendered  all  the  more 
difficult  when  gonorrhea  coexists. 

Chancres  of  the  Urethra 

I  believe  these  to  be  more  common  than  is  generally 
supposed,  and  the  reasons  for  this  are  obvious — they  are 
concealed  from  view,  cause  little  disturbance,  and  are  so 
likely  to  be  mistaken  for  gonorrhea  that,  in  nine  out  of 
ten  cases,  this  latter   happens,   at   least   until   things  are 


CLINICAL   COURSE:    CHANCRE  23 

well  developed.  Chancres  attacking  the  urethra  are  met 
with  usually  just  within  the  meatus  or  in  the  fossa 
naviculars,  but  may  occur  lower  down  the  urethra.  There 
is  pain  on  micturition  ;  slight  thin  yellow  discharge  and 
hardness  can  be  detected  along  the  urethra  in  a  circum- 
scribed degree ;  sometimes  when  the  finger  is  passed 
along  the  course  of  the  canal  it  gives  the  sensation  as  if 
there  was  "  a  piece  of  the  stem  of  a  clay  pipe "  in  it. 
These  lesions  can  best  be  detected  by  means  of  internal 
manipulation  or  seen  through  a  meatus  canula  of  a 
urethroscope. 

Chancre  of  Base  of  Penis 

Occurs  on  the  skin  on  or  about  the  root  of  the  penis. 
When  first  seen  it  looks  like  a  scratch  or  abrasion  about 
the  size  of  a  pea  ;  this  enlarges  slowly,  becomes  eroded, 
flat  or  depressed,  until  it  reaches  the  size  of  a  sixpence, 
or  in  some  cases  a  shilling  ;  it  is  nearly  always  circular 
in  shape,  edges  markedly  hard,  and  when  taken  between 
the  fingers  laminated  induration  is  well  marked — in  fact,  it 
is  in  these  chancres  that  this  form  of  induration  is  best 
marked. 

The  surface  of  the  chancre  erodes  and  sometimes 
ulcerates,  but  the  latter  is  rare ;  it  is  covered  with  a 
whitish  yellow  false  membrane,  on  the  removal  of  which 
a  weeping  surface  is  left.  Sometimes  the  surface  looks 
like  the  top  of  a  pepper  caster. 

Chancre  of  the  Scrotum 
Commences   as   a   patch    of    circumscribed    erythema. 
The  skin  soon  desquamates   and   leaves  little   cracks   or 


24      SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

fissures  exuding  a  clear  serum  ;  these  cracks  unite  by 
erosion,  and  a  shallow  ulcer,  circular  in  shape,  situated 
on  a  hard  base  and  with  well-marked  indurated  edges, 
remains.  In  other  cases  the  surface  of  this  form  of  chancre 
is  covered  with  brownish  crusts  of  dried  epithelium,  which 
keeps  on  re-forming  as  often  as  removed,  or  again  the 
syphilitic  lesion  in  this  locality  may  be  in  the  form  of  a 
tubercle. 

Preputial  Chancres 

When  placed  at  the  end  or  termination  of  the  prepuce, 
these  chancres  are  ragged,  and  give  the  end  of  the  prepuce 
the  appearance  of  having  been  split  in  one  or  two 
directions  ;  these  splits  look  at  first  like  scratches,  the 
edges  of  which  are  indurated  or  generally  inflamed.  The 
prepuce  in  this  situation  is  usually  thickened. 

Sub-preputial  or  Concealed  Chancres 

A  chancre  of  the  prepuce  may  be  rendered  invisible 
owing  to  phimosis,  either  congenital  or  acquired,  the  latter 
being  the  result  of  the  inflammation  caused  by  this  very 
chancre. 

In  this  case,  besides  the  phimosis,  there  will  be  a  thin 
yellowish  discharge,  which  can  be  gently  squeezed  out ; 
little  or  no  pain  on  urinating,  or  other  sign  of  gonorrhea. 
Should  an  indurated  sore  be  present  beneath  the  foreskin, 
this  hardening  can  generally  be  felt  by  manipulating  the 
member  with  the  fingers.  But  in  any  case  the  surgeon 
ought  seldom  to  be  long  in  doubt,  as  means  ought  to  be 
taken  to  expose  the  sore  at  once. 


CLINICAL   COURSE:    CHANCRE  25 

Chancres  of  the  Anus 

These  may  be  situated  at  the  margin  of  or  entirely  within 
the  anus.  The  former  generally  present  a  thickened, 
fissured  and  ulcerated  surface  devoid  of  deep  redness. 
They  are  of  a  rose-red  tint,  and  present  a  medium  degree 
of  induration  at  their  bases.  Sometimes  these  chancres 
assume  the  characters  of  fissures  with  pale,  smooth  margins 
and  pale-red  surface.  Their  bases  are  resistant  to  the 
touch,  and  they  are  far  less  tender  than  ordinary  "  fissure  " 
of  the  anus — an  important  point  in  diagnosis. 

When  situated  within  the  anus  the  chancre  will,  of 
course,  be  concealed. 

Chancre  of  Groin 

This  chancre  comes  within  the  scope  of  perigenital 
chancres.  It  may  occur,  a  priori,  from  direct  inoculation, 
or  as  a  secondary  contagion  to  an  open  bubo.  In  the 
first  case  it  will  appear  like  an  indurated  chancre  of  the 
general  integument,  to  be  afterwards  described.  Should 
an  open  bubo  become  infected  with  syphilitic  virus,  the 
chancre  will  generally  attack  one  or  both  lips  of  the 
wound.  The  latter  remains  gaping,  and  a  sore  or  nodule 
appears  on  one  of  the  lips.  This  slowly  enlarges  until 
an  ulcer  is  formed,  which  soon  becomes  planted  on  a 
well-marked  indurated  base.  The  open  bubo  may  con- 
tinue to  heal,  all  except  the  part  at  and  about  the 
chancre,  which  remains  open  and  indolent-looking. 


26      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Chancroid  Inflammation 

The  chancroid  virus  may  be  implanted  simultaneously 
with  or  later  than  the  syphilitic.  In  either  case  the 
character  of  the  syphilitic  chancre  will  be  modified  in 
appearance.  Of  course  it  would  be  quite  possible  for 
the  chancroid  to  heal  up  before  the  syphilitic  virus  took 
effect,  but  this  would  be  the  exception.  More  commonly 
the  chancroid  persists,  the  spreading,  inflamed,  punched- 
out-looking  ulcer  becoming  gradually  enveloped  in  in- 
duration as  the  full  local  development  of  the  syphilitic 
lesion  is  reached.  In  the  other  case,  when  the  chancroid 
virus  is  inoculated  on  the  chancre,  the  result  is  chancroidal 
ulceration,  on  the  disappearance  of  which  the  induration 
remains.  Ulceration  of  a  chancroid  may  cause  sloughing 
of  an  indurated  mass — a  result  which  leaves  no  local 
indication  of  syphilis. 

A  sore  of  the  above  description  is  called  a  "  mixed 
chancre." 


CHAPTER    IV 

DIAGNOSIS  AND   PROGNOSIS 

It  is  wise  never  to  give  a  positive  opinion  as  to  the  nature 
of  a  chancre  simply  on  the  local  examination  of  the  lesion 
itself,  as  although  in  most  cases  it  may  be  an  easy  matter 
to  form  a  definite  opinion  from  this  alone,  still  it  must 
be  remembered  that  it  has  no  certain  sign. 

Signs  of  a  Syphilitic  Sore 

i.  Its  incubation — a  sore  beginning  in  from  ten  days 
to  four  weeks  after  exposure. 

2.  A  sore  beginning  as  a  painless  macule  or  slight 
erosion,  spreading  slowly  and  becoming  indurated,  exuding 
a  thin  scanty  discharge  from  its  surface,  which  latter  may 
be  covered  with  crusts  or  false  membrane. 

3.  Should  it  be  followed  by  the  neighbouring  glands 
becoming  increased  in  size,  without  pain  or  inflammation, 
forming  a  chain  of  little  tumours,  the  evidence  of  the 
syphilitic  nature  of  the  lesion  is  much  strengthened. 

4.  Should  the  Spirochceta  pallida  be  found  in  the  secretion 
from  the  sore,  then  a  definite  opinion  may  be  given  as 
to  its  nature. 

5.  A  positive  reaction  with  Wasserman's  test  will  of 
course  strengthen  the  evidence. 

27 


28      SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

Difficulties  of  Diagnosis 

The  difficulties  of  diagnosis  met  with  are :  the  history 
of  incubation  may  be  vague  and  uncertain  ;  induration 
absent,  or  marked,  or  so  slight  as  to  be  indefinable  ;  en- 
largement of  neighbouring  glands  may  be  absent ;  the 
non-discovery  of  the  Spirochata  pallida  in  the  sore — 
always  a  difficult  matter  to  find  it  in  primary  sores/ 

Differential  Diagnosis  of  Chancres 

The  character  of  a  mixed  chancre  having  already  been 
discussed,  it  suffices  here  to  say  that  when  a  sore  appears 
later  than  ten  days  after  exposure,  followed  by  induration 
which  becomes  inflamed  and  ulcerated,  with  consequent 
destruction  of  the  induration,  which  makes  the  lesion  look 
like  a  simple  one,  the  probability  is  that  it  is  a  mixed 
chancre  ;  being  in  other  words  a  syphilitic  chancre,  which, 
becoming  infected  by  some  septic  matter,  has  taken  on  the 
features  of  a  soft  sore  from  inflammation  and  ulceration. 

It  would  thus  lose  the  distinction  of  the  induration,  and 
presenting  only  the  features  of  the  simple  sore,  the 
probability  is  that  it  is  a  mixed  chancre,  which  surmise 
will  be  further  strengthened  should  the  lymphatic  glands 
in  the  neighbourhood  become  indolently  enlarged. 

DIAGNOSTIC    POINTS    BETWEEN    A 
CHANCRE  AND   CHANCROID 

Chancre  Chancroid  (Soft  Chancre) 

Origin  Origin 

Due  to  inoculation  from         Due  to  inoculation   from 

syphilitic    lesion,   blood,   or  chancroidal  discharge, 
other  syphilitic  discharge. 


DIAGNOSIS  AND  PROGNOSIS 


29 


Incubation 
Over   ten   days ;   average 
time,  three  to  four  weeks. 

Com  mencemen  t 
Erosion,  papule  or  ulcer. 

Number 
Single,  at  times  multiple 
(exceptional). 

Shape 
Symmetrically  irregular. 

Depth 
Superficial        erosion, 
scooped    out,    flat    or    ele- 
vated. 


Edges 


Sloping. 


Incubation 
No  definite  period  ;  gener- 
ally under  five  days. 

Commencement 
Pustule  or  open  ulcer. 

Number 
As  a  rule  multiple ;  often 
on   opposing  surfaces,  from 
auto-inoculation. 

Shape 
Round,  oval. 

Depth 
Deep,   perforating    whole 
thickness  of  skin  and  mu- 
cous membrane. 

Edges 
Abrupt  and  sharply  cut. 

Floor 
Whitish  grey  or  yellow. 


Floor 
Red,      livid,      copper- 
coloured  ;    often    iridescent. 
Sometimes      covered      with 
false  membrane. 

Secretion  Secretion 

Scanty     sanious     serum.  Abundant   and    purulent. 

Not  readily  auto-inoculable,      Readily  auto-inoculable. 
and  only  so  during  first  ten 
days  of  existence. 


3o      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 


Induration  Induration 

Exists  as  a  rule:  firm, car-         No  induration,  as  a  rule; 
tilaginous,  circumscribed.  if  present,  not  circumscribed, 

but  shades  off  into  adjacent 
tissues. 


Frequency  in  one  Subject 
One  chancre  affords  pro- 
tection   in    ninety-nine   per 
cent,  of  cases. 


Frequency  in  one  Subject 
No  protection. 


Glandular  enlargement 

Neighbouring  glands  in- 
dolently enlarged,  firm, 
movable,  no  inflammation. 
When  the  sore  is  situated  on  enlarged 
penis,  glands  of  both  groins 
uniformly  enlarged.  No 
pain. 


Glandular  enlargement 
Inflamed,  painful    irregu- 
lar suppuration.     Glands  on 
both    sides    not     uniformly 


Micro-organism 
Present :    Spirochceta  pal- 
lida generally  found. 


Micro-organism 
Spirockceta  pallida   never 
present.     Ducrey's    bacillus 
present. 

Effects  of  Treatment. 
Local  treatment  curative. 


Effects  of  Treatment 
Local   treatment    ineffec- 
tual. 

Auto-I  noculation 
It   was  formerly  believed  that  the  chancre  was  never 
auto-inoculable ;  it  is  now  an  established  fact  that  during 
at   least  the    first   fortnight   of  its   existence   it   is    auto- 


DIAGNOSIS  AND  PROGNOSIS  31 

inoculable — that  is,  is  capable  of  reproducing  a  like  lesion 
if  inoculated  in  some  other  part  of  the  body.  Mercuralisa- 
tion  of  the  patient  renders  this  impossible. 

Syphilis  and  Yaws 

The  one  other  disease  in  which  the  Spirochceta  pallida 
was  thought  to  have  been  found,  is  the  one  which 
mostly  resembles  syphilis — namely,  Yaws  (parenga  or 
pian).     The  points  of  difference  between  them  are  : 

Syphilis  Yaws 

1.  Primary  lesion.  1.  No  primary  lesion. 

2.  Induration  generally  marked.  2.  No  induration. 

3.  Neighbouring  glands  en-  3.  No  glandular  enlargements, 
larged  and  nodular. 

4.  Auto-inoculable     up     to     a  4.  Always  auto-inoculable. 
certain  time  only. 

5.  Apes  which  have  been  in-  5.  Apes  capable  of  being  in- 
fected with  syphilis  unable  to  fected  by  inoculation  and  re- 
transmit same  to  those  already  transmitting  yaws  to  other  apes, 
suffering  from  syphilis.  and     to     those     suffering     from 

syphilis. 

Castellani  now  differentiates  between  the  Spirochceta  pal- 
lida and  the  organism  which  he  believes  to  be  the  cause 
of  yaws,  and  which  he  calls  Treponema  pertenue. 

Extragenital  Chancres 

Chancres  may  be  situated  on  any  part  of  the  body, 
but  are  found  generally  on  those  parts  which  are  most 
exposed  to  infection,  such  as  the  mouth,  tongue,  and  tips 
of  fingers. 


32      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Modes  of  Conveyance 

These  may  be  either  direct  or  mediate  :  by  direct  contact 
with  a  syphilitic  lesion,  as  by  kissing ;  or  by  mediate 
contagion  through  contaminated  spoons,  forks,  drinking 
utensils,  pipes,  etc.,  etc.,  and  again  through  the  agency  of 
infected  surgical  or  dentists'  instruments. 

Principal  Extragenital  Chancres 

It  will  be  necessary  here  to  consider  a  few  of  the  most 
important  extragenital  chancres,  as  their  diagnosis  is 
often  rendered  difficult  owing  to  the  position  or  locality 
in  which  they  are  situated. 

Chancre  of  the  Lip 

Begins  as  a  chap  or  fissure.  At  first  there  is  nothing 
characteristic  about  it,  but  in  time  it  becomes  an  indolent 
ulcer  with  early  marked  "  cartilaginous  "  induration  ;  later 
on  the  submental  glands  become  indolently  and  pain- 
lessly enlarged.  In  appearance  it  is  an  indolent  elevated 
sore,  papule  or  pustule  ;  its  surface  is  smooth,  and  exudes 
a  scanty,  glistening  discharge.  When  taken  between  the 
thumb  and  finger  it  feels  like  a  lump  of  gristle. 

The  chief  lesion  that  labial  chancres  may  be  mistaken 
for  is  epithelioma,  but  the  following  points  may  serve 
to  differentiate  between  them  : 


Labial  Chancre 

Labial  Epithelioma 

Age 

Age 

Any. 

Generally    about    middle 

life. 

DIAGNOSIS  AND  PROGNOSIS  33 

Site  Site 

Usually  upper  lip.  Involves  lower  lip  gener- 

ally. 


Sex 


Both. 


Local  Symptoms 
A  painless  papule,  erosion 
or  ulcer.  Regular  outline, 
surface  smooth  and  has  in- 
durated edges  ;  discharge  is 
scanty  and  thin. 

Course 
Develops  in  a  few  weeks, 
followed  in  about  two  weeks 
by    submaxillary   glandular 
enlargements. 

Spirochceta  pallida 
Present. 

Mercury 
Causes  disappearance. 


Sex 
Nearly  always  the  male. 

Local  Symptoms 
A  painful,  irregular,  rugged 
sore,  bleeds  easily;  if  indura- 
tion be  present  it  is  irregular ; 
discharge  thick  and  offen- 
sive. 

Course 
Develops  very  slowly, 
taking  as  many  months  as 
the  chancre  does  weeks. 
Glands  not  affected  for 
months  after  sore  appears. 

Spirochceta  pallida 
Not  found. 

Mercury 
No  effect. 


Chancre  of  Tongue 

Chancres    of    the    tongue    involve    the    anterior    half, 
dorsum,  sides,  or  tip  ;  and  may  appear : 

1.  As  a  superficial  erosion  seated  on  an  indurated  base. 

2.  As  a  deep  ulcer  with  sloping  edges  on  a  hard  base. 

3.  As  a  dense  sclerotic  mass  with  unbroken  surface. 

3 


34      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Chancre  of  the  tongue  very  often  simulates  an  ulceration 
caused  by  a  carious  tooth. 

Chancre  of  Tonsil 

This  is  rare,  but  may  be  mistaken  for  some  ordinary  throat 
affection,  from  which  it  may  be  differentiated  by  its  being 
unilateral,  indurated,  persistent,  and  accompanied  by  in- 
dolent glandular  swellings  under  the  sterno-cleido  mastoid. 

Chancre  of  the  Eye 

This  may  be  palpebral  or  conjunctival.  Contagion  may 
be  carried  by  the  fingers,  by  spitting,  or  by  a  contaminated 
towel.  The  surgeon  may  become  infected  during  ex- 
amination of  the  throat  or  mouth  of  a  syphilitic  patient  ; 
one  of  the  worst  cases  of  syphilis  I  have  seen  occurred 
in  a  surgeon  who  during  an  operation  was  infected  by 
some  matter  finding  its  way  into  the  eye. 

Appearance. — An  ocular  chancre  usually  begins  as  a 
papule,  which  generally  becomes  indurated,  then  eroded, 
and  sometimes  ulcerated,  and  is  followed  by  indolent 
enlargement  of  the  glands  in  the  vicinity  of  the  ear  and 
angle  of  jaw. 

Chancre  of  the  palpebral  margin  may  be  mistaken  for 
a  stye,  an  error  which  may  be  avoided  by  watching  the 
development  of  induration  and  the  glandular  swellings 
which  always  accompany  the  former. 

Conjunctival  chancres  may  be  found  on  the  palpebral 
or  ocular  conjunctiva,  but  more  often  on  the  former,  in 
which  case  the  eyelid  is  everted,  and  there  is  conjunctivitis 


DIAGNOSIS  AND  PROGNOSIS  35 

and  chemosis.     The  chancre   may  be  nodular,  round,  or 
oval,  or  a  simple  hard  erosion. 

Facial  Chancre 

Facial  Chancre  may  occur  from  kissing,  spitting,  or  razor- 
cuts,  the  latter  being  not  uncommon.  The  cut,  having 
healed,  reopens,  and  becomes  covered  with  crusts  and  sur- 
rounded by  induration,  and  erosion  and  ulceration  follow, 
with  indolent  swellings  of  the  submaxillary  and  parotid 
glands.  I  have  recently  seen  a  chancre  on  the  cheek  of  a 
medical  man,  the  result  of  a  razor-cut  becoming  infected 
whilst  he  was  attending  a  midwifery  case.  These  lesions 
are  generally  well  marked,  and  easy  to  diagnose,  but  have 
been  mistaken  for  sycosis  and  eczema. 

Chancre  of  Finger 

Of  all  extragenital  chancres  those  of  the  fingers  are 
most  common,  occurring  generally  among  medical  men, 
dentists,  and  midwives  ;  but  they  may  arise  in  any  one, 
and  have  often  occurred  as  the  result  of  bites.  They 
usually  are  found  at  the  edges  or  base  of  the  nail ;  they 
are  most  commonly  eroded,  and  often  ulcerated,  induration 
being  well  marked  and  extensive.  Oftentimes  this  class 
of  sore  develops  so  insidiously  and  looks  so  innocent 
that  it  goes  unnoticed  by  the  patient,  and  is  apt  to  be 
overlooked  until  later  symptoms  appear.  On  the  other 
hand,  this  chancre  may  develop  into  a  large,  hard,  fleshy 
mass,  purplish  in  colour,  of  soft  surface,  with  exuberant 
vegetations  on  it.  One  type  of  sore  resembles  a  whitlow ; 
the  terminal  phalanx  of  the  finger  is  red,  swollen,  painful 


36     SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

and  sensitive,  whilst  the  surrounding  tissue  is  indurated. 
These  chancres  are  remarkable  for  their  long  duration 
and  painful  character ;  the  nail  nearly  always  separates 
from  the  finger,  and  very  often  the  bone  necroses.  In 
such  sores  the  axillary  and  epitrochlear  glands  always 
become  indolently  enlarged. 

Vaccination  Chancre 

This  is  much  rarer  now  compared  with  the  days  of 
arm-to-arm  vaccination.  If  the  vaccination  "takes,"  the 
pustules  run  a  normal  course  and  heal  up ;  or  healing  may 
be  delayed,  leaving  an  ulcer  with  smooth  surface  exuding 
a  scanty  discharge.  It  is  painless,  and  soon  becomes 
indurated ;  and  later  the  anatomically  related  glands 
become  enlarged  and  nodular.  Should  the  revaccination 
not  "  take,"  a  characteristic  chancre  forms. 

Chancre  of  the  Breast 

This  is  usually  caused  by  a  syphilitic  infant  nursed  by  a 
healthy  woman.  The  lesion  appears  either  on  or  about 
the  nipple  or  on  the  mammary  integument.  It  may  begin 
as  a  fissure,  crack,  or  erosion  without  pain,  exude  a 
scanty  sanious  discharge,  and  finally  become  indurated 
and  accompanied  by  indolently  enlarged  axillary  glands. 

Chancres  of  the  General  Integument 

Chancres  occur  at  any  point  of  the  body  which 
may  have  been  exposed  to  infection — e.g.  in  the  process 
of  tattooing. 


DIAGNOSIS  AND  PROGNOSIS  37 

PROGNOSIS  OF  CHANCRE 

From  a  local  point  of  view  this  is  always  favourable  ; 
generally  at  the  end  of  three  or  four  weeks  the  chancre 
becomes  cicatrised  and  the  induration  disappears,  leaving  a 
scar  which  is  at  first  pigmented  but  eventually  becomes 
white.  The  healing  of  the  sore  will  depend  very  much  on 
the  constitutional  treatment,  but  even  without  this  it  will 
often  ensue  spontaneously.  Ulceration  from  a  syphilitic 
chancre  seldom  leaves  any  deformity,  owing  to  the  fact 
that  any  destruction  of  tissue  is  at  the  expense  of  the 
infiltration  ;  deformity  will,  of  course,  result  from  phage- 
dena. Chancres  situated  in  certain  parts  will  often  give 
rise  to  grave  symptoms :  for  instance,  on  the  tongue  or 
tonsil,  causing  difficulty  of  mastication  and  swallowing ; 
or  in  the  eye,  leading  to  severe  ophthalmia,  and  in  the 
urethra  producing  stricture. 

Relation  of  Character  of  Chancre  to  Subsequent 
Progress  of  the  Disease 

What  relation,  if  any,  exists  between  the  source  of 
contagion  and  character  of  the  chancre,  and  the  subsequent 
progress  of  the  disease?  This  question  has  led  to  much 
discussion,  but  the  following  deductions  appear  to  be 
justified : 

i.  It  is  impossible  to  predict  the  form  of  chancre  which 
will  follow  from  a  certain  source  of  infection. 

2.  Many  authorities  think,  and  to  a  certain  extent  I 
agree  with  them,  that  the  severity  of  the  constitutional 
disease  bears  a  relation  to  the  character  of  the  primary 


38      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

sore ;  i.e.  an  ulcerating  sore  is  more  often  the  prelude  to 
one  of  the  severer  forms  of  eruption  than  an  ordinary- 
dry  papule,  and,  generally  speaking,  the  more  marked  the 
induration  the  more  likely  are  sclerotic  lesions  to  follow. 
3.  A  short  primary  or  secondary  incubation  denotes 
the  probability  of  a  severe  case.  Hallepeau  maintains 
that  chancres  situated  on  the  prepuce  or  vulva  and  at 
the  anus  are  more  often  followed  by  severe  symptoms 
than  those  found  elsewhere :  the  writer's  experience  is 
that  the  worst  forms  of  syphilis  he  has  seen  have  followed 
one  of  the  extra-genital  chancres. 

Primary  Lymphatic  Enlargements 

At  the  end  of  the  first  or  second  week  after  the 
appearance  of  the  chancre  the  lymphatic  vessels  leading 
from  it  may  be  felt  enlarged,  like  whipcord,  though 
there  is  no  pain  or  inflammation ;  at  the  same  time 
the  glands  associated  with  these  vessels  become  pain- 
lessly enlarged  and  hard.  The  glands  thus  affected 
are  those  in  the  immediate  vicinity  of  the  chancre :  the 
inguinal  in  the  case  of  genital  chancres,  the  submaxillary 
and  submental  in  chancres  of  the  tongue  or  lips,  the 
preauricular  glands  in  chancres  of  the  eyelid,  and  the 
axillary  in  those  of  the  fingers.  These  enlargements  are 
never  great,  hardly  ever  exceeding  the  size  of  a  marble, 
are  hard,  indolent,  painless,  and  easily  movable,  and 
scarcely  ever  suppurate.  Rarely  is  it  that  a  syphilitic 
chancre  is  unaccompanied  by  these  enlargements ;  at  the 
same  time  it  must  be  remembered  that  these  vessels  and 
glands  are  also  liable  to  become  enlarged  as  the  result 


DIAGNOSIS  AND  PROGNOSIS  39 

of  the  presence  of  a  chancroid,  herpes,  or  any  other  local 
irritation.  The  following  points  may  help  to  differentiate 
between  the  two  conditions : 

_       ._    _         ,         .  .  Inflammatory  Lym- 

Specific  Lymphangitis  phangitis 

Hard  and  painless  ;  no  Hard,  painful,  tender,  and 
inflammation;  terminates  in  red  ;  overlying  skin  cedema- 
resolution  under  specific  tous;  often  ends  in  suppura- 
treatment  tion,  not  affected  by  specific 

treatment. 

The  same  points  will  also  apply  to  the  glands  them- 
selves. 


CHAPTER   V 

TREATMENT  OF   CHANCRE 

Persistent  efforts  have  been  made  from  time  to  time 
to  set  aside  the  possibility  of  syphilis  by  the  destruction 
of  the  primary  lesion,  either  by  excision,  chemical  means, 
or  by  the  actual  cautery.  Results  have  been  disappointing, 
as  not  only  have  the  measures  of  destruction  failed  to 
relieve  the  local  symptoms,  but  also  to  prevent  secondary 
signs.  In  the  face  of  these  results  the  question  arises, 
ought  excision  of  the  primary  lesion  to  be  carried  out? 
If  this  lesion  is  looked  on  as  but  the  local  expression 
of  an  intoxication  generalised  at  the  outset,  common 
sense  would  point  to  the  uselessness  of  such  a  procedure. 
On  the  other  hand,  if  the  view  of  probably  the  majority 
of  syphologists  of  to-day  be  adopted — that  the  initial 
sore  or  lesion  is  the  local  point  from  which,  after 
multiplication,  the  microbe  of  the  disease  or  its  toxin 
is  swept  through  the  system — then  I  should  say  that, 
given  certain  conditions,  the  destruction,  either  by  excision 
or  otherwise,  of  the  sore  should  be  done.  But  there  is 
only  one  class  of  case  in  which  this  abortive  method  is 
applicable  with  any  reasonable   hope  of  success — in   the 

case   of    a    very   young   chancre   of    a   few   hours'    date, 

40 


TREATMENT  OF  CHANCRE  41 

without  induration  and  without  satellite  glands.  Un- 
fortunately such  conditions  greatly  restrict  the  applica- 
bility of  the  proceeding,  as  ninety-nine  out  of  a  hundred 
chancres  seen  have  been  in  existence  for  days,  and,  in 
fact,  the  chancre  met  with  fulfilling  the  conditions  indicated 
must  be  a  rare  event. 

Destruction  of  the  Syphilitic  Virus  in  Situ 

The  experimental  work  of  Metchnikoff  shows  that  the 
syphilitic  poison  can  easily  be  destroyed  in  the  laboratory 
by  drying,  cooling  to  a  point  below  500  F.,  or  by  heating 
it  to  a  temperature  of  1220  F.  for  half  an  hour.  From  this 
fact  he  has  endeavoured  to  destroy  the  Spirochceta  pallida 
in  situ  by  thoroughly  rubbing  into  the  point  of  inoculation 
an  ointment  consisting  of  calomel  10  gms.,  lanolin  and 
vaseline  30  gms.,  and  is  satisfied  this  will  prevent  infection 
if  done  within  eighteen  hours  of  inoculation.  He  had  the 
advantage  of  proving  this  on  the  person  of  a  student  who 
offered  himself  for  such  experiment,  and  in  this  case  it 
was  a  complete  success.  The  same  results  have  followed 
in  the  case  of  innumerable  monkeys,  which  were  inoculated 
with  the  virus  and  controlled.  Without  doubt  it  is  a 
procedure  which  should  be  preached  broadcast. 

As  regards  the  local  treatment  of  chancre,  it  is  of  the 
utmost  importance  that  no  stimulating  nor  caustic  applica- 
tions should  be  made  ;  for,  in  the  first  place,  should  the 
lesion  be  simple  in  nature,  burning  it  with  acids,  etc.,  will 
not  destroy  it,  but  will  transform  it  into  an  inflammatory 
nodule,  and  cause  it  to  markedly  resemble  a  hard  chancre, 
and  thus  doubt  and  uncertainty  in  diagnosis  is  the  result. 


42      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

On  the  other  hand,  if  the  lesion  is  an  incipient  chancre, 
cauterisation,  however  complete,  cannot  destroy  it,  but 
may  cause  an  oedema  which  may  be  troublesome  to  cure. 
Any  breach  of  surface,  therefore,  should  be  kept  scrupu- 
lously clean,  and  be  covered  with  lint  or  absorbent  cotton 
moistened  with  boiled  or  distilled  water,  or  a  mild  sub- 
limate solution  (i  in  2,000),  or  very  dilute  carbolic  lotion 
applied  ;  peroxide  of  hydrogen,  1  in  6  of  water,  makes 
a  good  application.  As  the  chancre  increases  in  size  it 
may  be  dressed  with  black  or  yellow  wash. 

Powders,  such  as  boric  acid,  aristol,  europhen,  dermatol, 
and  last,  but  not  least,  iodoform,  dusted  on  may  be  of 
great  benefit.  The  best  of  these  is  iodoform  ;  its  odour 
is  certainly  against  it,  but  with  care  much  of  this  incon- 
venience may  be  obviated.  It  should  be  used  sparingly, 
and  not  allowed  to  fall  on  sound  parts  or  upon  clothes. 
Should  the  sore  be  under  the  prepuce  it  may  be  kept  at 
a  minimum  by  packing  cotton  in  the  preputial  orifice. 
It  must  be  remembered  that  iodoform  is  applicable  only 
to  unhealthy  and  necrotic  surfaces,  and  should  be  dis- 
continued when  these  cease. 

In  the  case  of  chancres  covered  with  a  false  membrane, 
or  those  which  have  a  tendency  to  ulcerate  and  become 
destructive,  it  is  important  that  a  caustic  effect  should 
be  produced,  and  this  is  best  done  by  washing  the  lesion 
well  with  soap  and  water,  and  then  irrigating  it  with 
a  5  per  cent,  carbolic  solution.  It  should  be  dried,  and 
a  solution  of  cocaine  applied  to  it,  and  then  it  should 
be  dried  again.  Better  still,  as  a  preparatory  method, 
is   to  mop  the  surface  freely  with  peroxide  of  hydrogen, 


TREATMENT  OF  CHANCRE  43 

equal  parts  with  water,  or  with  Merck's  perhydrol ;  apply 
the  cocaine,  dry  the  parts,  and  then  apply  the  caustic ; 
for  the  latter  nothing  is  better  than  fluid  carbolic  acid 
or  pure  nitric  acid. 

Calomel  very  often  acts  promptly  and  efficiently  on 
chancres  showing  a  disposition  to  destruction,  and  is 
always  a  useful  dry  dressing  in  clean  but  indolent  sores. 

Bearing  in  mind  that  the  indurated  chancre  is  probably 
the  seat  where  the  spirochastae  multiply  and  the  focus 
from  whence  they  spread  throughout  the  system,  it  is 
all-important  that  a  specific  action  be  brought  to  bear 
on  all  chancres  which  show  a  tendency  to  become  in- 
durated. Having  by  proper  means  produced  a  healthy 
surface,  the  chancre  should  be  treated  with  mercurial 
ointment.  The  surface  having  been  washed  and  rendered 
as  nearly  as  possible  aseptic,  a  layer  of  absorbent  lint 
well  smeared  with  Ung.  hydrarg.  MetchnikofFs  30  per  cent, 
of  calomel  ointment,  or  oleate  of  mercury,  5  per  cent, 
should  be  placed  upon  it  and  kept  in  constant  apposition, 
and  this  dressing  should  be  changed  two  or  three  times 
a  day. 

As  a  rule,  salves  and  ointments  (other  than  mercurial) 
should  be  avoided,  exception  being  made  when  the  dis- 
charge is  thick  and  sticky. 

The  Treatment  of  Phagedenic  Chancres 

The  treatment  of  chancres  complicated  with  phagedaena 
is  exceptional ;  most  to  be  depended  on  is  continual 
immersion  in  hot  antiseptic  solutions.  In  the  case  of 
such  a  sore   on  the  penis    this    can  best  be  carried   out 


44      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

by  immersing  the  latter  in  hot  water  contained  in  such 
a  vessel  as  a  bed-urinal,  allowing  it  to  remain  there  for 
long  periods :  the  water,  of  course,  requires  frequent 
changing ;  an  ordinary-size  bath  may  be  used  for  the 
same  purpose.  Should  the  phagedaenic  action  go  on, 
cauterisation,  either  by  chemical  means  or  the  actual 
cautery,  must  be  undertaken.  The  best  of  the  former 
is  crude  chromic  acid.  The  patient  should  be  placed 
under  a  general  anaesthetic,  or  the  parts  rendered  in- 
sensible by  a  local  one  (I  prefer  the  former) ;  then  the 
sore  having  been  thoroughly  dried,  the  chromic  acid  is 
applied  to  it ;  a  black  slough  remains,  and  this  is  detached 
by  charcoal  poultices,  leaving  a  healthy  surface  as  a  rule  ; 
however,  a  second  application  may  be  required.  Instead 
of  chromic  acid,  strong  nitric  acid  may  be  used.  Some 
cases  of  phagedena  may  require  the  actual  cautery,  and 
all  require  watching,  as  they  are  rapid  in  their  progress, 
and  require  prompt  recognition  and  treatment. 


CHAPTER   VI 
SECONDARY   PERIOD 

The  Period  of  Secondary  Incubation 

The  period  of  secondary  incubation  is  the  time  between 
the  appearance  of  the  chancre  and  the  development  of 
secondary  lesions,  and  this  averages  from  forty  to  fifty 
days,  during  which  the  chancres  may  have  healed  and 
disappeared  completely,  and  the  disease,  as  far  as  any 
constitutional  symptoms  are  concerned,  appear  to  be 
quiescent.  Undoubtedly  during  this  time  the  virus  is 
becoming  disseminated  throughout  the  system. 

The  conditions  influencing  the  length  of  this  period 
are  the  presence  of  malignant  syphilis,  or  when  the  disease 
attacks  constitutions  which  are  already  undermined  from 
various  causes.  Then  the  period  of  secondary  incubation 
is  shortened,  whereas  the  contrary  takes  place  when  the 
disease  attacks  those  of  robust  constitution,  or  when  it 
is  of  a  non-virulent  kind. 

The  Evolution  of  Syphilis 

After  this  comes  the  stage  of  secondary  symptoms, 
during   which,  to   begin   with,  the   virus   manifests   itself 

45 


46      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

on  the  accessible  lymphatic  glands  not  anatomically  con- 
nected with  the  primary  lesion. 

Already  it  has  been  seen  that  within  a  week  or  so 
after  the  appearance  of  the  leison,  those  lymphatic  vessels 
and  glands  in  its  vicinity  become  enlarged  and  indurated  ; 
but  care  must  be  taken  to  differentiate  between  this  and 
the  enlargement  of  the  glands  under  consideration.  The 
glands  which  are  most  affected  are  those  situated  in 
the  neck,  axilla,  and  groin,  all  of  which  become  swollen 
as  a  result  of  the  essential  hyperplastic  process  produced 
by  the  virus.  It  is  now  generally  recognised  that  the 
changes  in  the  deep  glands  are  among  the  most  frequent 
and  most  constant  of  the  effects  of  syphilis,  either  in 
its  secondary  or  tertiary  stages  ;  in  other  words,  they 
are  its  constant  accompaniment.  The  other  glands  most 
frequently  affected  are  the  prevertebral,  lumbar,  iliac,  and 
femoral.  Specific  enlargement  of  the  lymphatic  vessels 
and  glands  is  characterised  by  three  symptoms — indura- 
tion, absence  of  inflammation,  and  persistency.  During 
the  course  of  the  disease  this  condition  of  the  vessels 
and  glands  may  disappear,  but  more  frequently  they 
remain  enlarged  for  months,  and  even  years,  after  all 
other  symptoms  of  the  existence  of  the  disease  have 
disappeared.  Resolution  without  suppuration  is  almost  the 
constant  termination,  but  suppuration  may  occur  should 
the  chancre  become  infected  with  pyogenic  microbes. 

Treatment 

Mercurial  ointment  should  be  well  rubbed  into  the 
skin  over  the  enlarged  glands  daily. 


SECONDARY  PERIOD  47 

Course  of  the   Disease 

The  general  or  constitutional  symptoms  which  usher 
in  syphilis  vary  in  different  cases.  In  some  there  is 
well-marked  fever,  especially  towards  evening,  when  it 
may  reach  as  high  as  1030  F. :  in  others  this  fever  presents 
a  distinctly  remittent  type.  Various  neuralgic  pains  are 
complained  of,  especially  headache,  which  is  nearly  always 
nocturnal,  and  which  varies  in  degree  from  being  quite 
mild  to  one  in  which  the  patient's  suffering  is  very  great. 
This  headache  generally  affects  the  back  of  the  head. 
Other  pains  of  a  neuralgic  kind  may  be  present,  attacking 
mostly  the  fifth  nerve,  and  may  be  seated  in  the  inter- 
costal, sciatic,  or  anterior  crural  nerves.  Insomnia  is 
a  symptom  sometimes  complained  of. 

Cachexia 

Early  in  the  secondary  stage  a  condition  known  as 
"  syphilitic  cachexia  "  takes  place — loss  of  appetite  and 
strength,  emaciation,  and  a  pale  sallow  complexion,  pulse 
rapid,  weak,  and  small — and  the  temperature  runs  up  : 
the  patient  is  dejected,  nervous,  and  apprehensive.  This 
condition  may  be  postponed  in  some  cases  (especially 
in  those  which  undergo  early  mercurial  treatment)  to 
quite  late  in  the  course  of  the  disease. 

The  Osteotic  Pains 

Osteotic  pains  of  different  kinds  are  a  frequent  accom- 
paniment in  the  early  period,  the  bones  affected  mostly 
being  the  cranium,  ribs,  sternum,  and  clavicle,  and  there 
may  be  great  tenderness ;  these  pains  and  this  tenderness 
are  much  worse  at  night. 


48      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Rheumatic  Pains 

Some  of  the  most  constant  symptoms  in  the  early- 
period  of  syphilis  are  pains  in  the  muscles,  fascia,  and 
joints,  the  muscles  affected  being  those  of  the  extremities, 
the  fascia  in  the  same  part,  and  the  joints  engaged  are 
usually  the  larger  ones — the  hip,  knee,  and  especially  the 
elbow — but  often  the  wrist  and  phalanges  are  attacked. 

Hyperemia  of  Pharynx  and  Tonsils 

One  of  the  points  in  which  syphilis  resembles  the 
acute  exanthemata  is  its  strong  tendency  to  attack  the 
fauces.  As  a  rule  the  throat  suffers  subsequent  to 
the  appearance  of  cutaneous  lesion,  but  frequently  the 
reverse  occurs;  very  often  it  is  affected  without  giving 
any  trouble,  and  is  only  discovered  on   inspection. 

In  many  cases  there  is  no  superficial  lesion  other  than 
slight  excoriation ;  in  others  mucous  patches  may  be 
present.  There  is  often  a  good  deal  of  tonsillar  swelling. 
The  follicles  become  enlarged  and  prominent ;  or  they 
may  rupture,  giving  rise  to  excoriations.  In  the  more 
chronic  cases  patches  are  present  on  the  tonsils  and 
palatine  arch ;  or  there  may  be  yellow  ulcers  sharply 
defined.  One  affection  constantly  seen  on  the  fauces, 
hard  palate,  inside  of  cheeks  and  lips,  is  scattered  milk- 
white  spots  called  "  plaques  "  ;  they  may  be  of  any  shape 
and  size,  or  they  may  run  into  each  other  so  as  to  cover 
a  large  space  ;  parts  of  their  surface  may  be  reddened, 
showing  only  a  little  white  opacity  here  and  there.  These 
spots  run  a  slow  course,  and  may  recur  over  and  over 
again  during  the  first   and  second   year  of  the  disease. 


SECONDARY  PERIOD  49 

Albuminuria  and  Nephritis 

About  this  time  albuminuria  may  appear,  and  there  is 
no  doubt  that  early,  and  sometimes  rather  late,  in  the 
secondary  stage,  a  mild  or  severe  form  of  nephritis  may 
occur. 

Some  authors  believe,  and  the  writer  is  with  them,  that 
syphilis  causes  the  same  condition  in  the  kidneys  as  do 
other  infectious  diseases. 

The  symptoms  of  this  nephritis  may  be  wanting,  and 
the  condition  only  discovered  by  examination  of  the 
urine ;  on  the  other  hand,  it  may  give  rise  to  oedema  of 
the  lower  extremities  and  face  with  lumbar  pain. 

The  majority  of  these  nephritic  cases  are  benefited  much 

by  antisyphilitic  treatment,  with,  of  course,  strict  attention 

to  diet. 

Angina  Pectoris 

This  condition,  with  all  its  classical  symptoms,  is  seen 

on    rare   occasions,  both   in    the   secondary   and   tertiary 

periods. 

SECONDARY   ERUPTIONS 

The  next  in  sequence  of  events,  as  the  case  proceeds, 
is  the  appearance  of  skin  eruptions.  Unlike  all  other 
specific  poisons,  that  of  syphilis  produces  not  one  or  two 
definite  cutaneous  affections,  but  an  immense  variety 
of  them.  They  are  known  as  syphilides  or  syphilo- 
dermata.  The  early  eruptions  of  the  secondary  stage  of 
syphilis  are  distributed  symmetrically  and  generally  over 
the  body,  involving  the  superficial  layers  of  the  skin  ; 
the    later   ones,  although    symmetrical,  are   less   copious, 

4 


5o      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

and  have  a  tendency  to  invade  the  deeper  layers  of  the 
skin. 

As  to  the  causes  which  influence  the  production  of  the 
different  forms  of  eruption,  we  are  in  ignorance.  All  that 
can  be  said  definitely  on  the  subject  is  that  a  patient  who 
is  in  a  bad  state  of  health  is  more  likely  to  develop 
eruptions  which  suppurate  and  ulcerate  than  he  would 
otherwise  have  been  if  infected  when  in  robust  health  ; 
and  that  patients  predisposed  to  certain  non-syphilitic 
skin  diseases,  such  as  ordinary  psoriasis  or  lichen,  are  apt 
to  be  affected  with  a  squamous  syphilide  or  with  a  papular 
one.  A  phagedenic  chancre  is  much  more  likely  to  be 
followed  by  pustular  eruptions  than  is  the  ordinary  in- 
durated sore.  The  fact  is  that  pustular  and  rupial  eruptions 
and  serpiginous  syphilides  are  really  the  results  of  mixed 
infections. 

Features  of  Syphilides 

To  almost  all  syphilides  certain  features  belong : 

1.  Colour  and  Pigmentation. — At  first  pinkish  red,  this 
soon  fades  to  a  brownish  colour,  said  to  be  coppery  or  to 
resemble  raw  ham  in  appearance,  the  cause  being  prob- 
ably some  chemical  change  in  disintegrating  blood-discs 
which  have  been  extravasated  into  the  tissues.  At  first 
pressure  dissipates  the  colour,  but  not  so  later  on. 

2.  Absence  of  Pain  and  Itching. — They  do  not  cause  any 
irritation  to  the  skin. 

3.  Tendency  to  assume  a  Circular  Form. — This  is  most 
noticeable  in  the  case  of  small  papular  rashes. 

4.  Polymorphism. — The  circumstance  of  several  varieties 


SECONDARY  PERIOD  51 

of  lesions   occurring    in    the  same  eruption  is  important. 
Sometimes  macular,    papular,  pustular,  and  scaly  patches 

are  present  together. 

5.  Peculiar  Localisation. — Syphilitic  eruptions  are  often 
found  in  regions  rarely  the  site  of  simple  lesions.  Syphilides 
are  irregular  in  their  distribution,  their  favourite  localities 
being  the  forehead,  the  sides  of  the  feet,  and  palms  of 
the  hands. 

Diagnosis  of  Syphilitic  Eruptions 

In  most  cases  a  correct  diagnosis  must  be  based  not 
so  much  upon  the  recognition  of  characters  common  to 
all  syphilides  as  upon  an  accurate  acquaintance  with  each 
of  them  individually.  It  is  therefore  essential  that  they 
should  be  classified.  Syphilides  may  be  divided  into 
those  which  appear  early  and  those  that  show  themselves 
late.  The  former  seldom  appear  beyond  the  first  twelve 
months  ;  the  latter  rarely  occur  within  the  first  year,  and 
their  appearance  may  be  postponed  for  several  years. 

Classification  of  Early  Syphilides 

I.     Erythematous. 

(Lichen. 
Acne. 

((a)  Psoriasis. 

III.  Papular  (Lenticular^    ,     ,,  ^ 

*  J\(b)  Mucous  Patches. 

IV.  Squamous. 
V.     Vesicular. 

VI.     Tertiary  Syphilides. 


52      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

The  Erythematous  or  Roseolar  Syphilide 
This  is  the  earliest  and  most  common  of  all  syphilitic 
skin  eruptions,  coming  out  about  the  same  time  that 
the  general  lymphatic  enlargements  become  apparent. 
It  consists  of  oval  or  round  spots,  with  distinct  or  irregular 
outlines ;  their  colour  varies  from  a  delicate  rosy  pink 
to  a  decided  red.  It  is  probably  present  in  all  cases  of 
syphilis,  but  may  escape  notice  on  account  of  its  extreme 
faintness.  It  is  usually  seen  on  the  front  of  the  abdomen, 
chest,  sides  and  back  of  trunk  ;  sometimes,  although  rarely, 
it  invades  the  face  and  neck.  It  is  also  found  on  the 
limbs  on  their  flexor  aspects  ;  it  avoids  the  hands  and 
feet.  It  takes  about  a  week  coming  out,  but  may  develop 
so  rapidly  as  to  be  taken  for  measles.  A  pale,  scanty 
eruption  of  roseola  often  fades  in  a  week  or  fortnight, 
whereas  a  darker  and  more  abundant  one  may  be  visible 
for  weeks,  and  then  may  assume  a  squamous  or  papular 
character.  This  syphilide  is  apt  to  relapse,  and  may 
occur  at  any  time  during  the  first  year,  and  even  in  the 
second. 

The  Follicular  Syphilide 
Of  this  there  are  two  distinct  varieties.  One  consists 
of  small,  pointed,  dry  elevations  or  papules,  generally 
scaly  at  the  summit,  and  their  bases  may  be  surrounded 
by  a  white  desquamating  cuticle ;  they  may  be  irregu- 
larly scattered,  or  in  clusters.  This  rash  is  slow  in  its 
course,  developing  itself  by  successive  crops,  and  subsiding 
after  several  weeks  or  even  months.  Sometimes  the 
little   papules    pass    into    pustules,   and   on    disappearing 


SECONDARY  PERIOD  53 

always  leave  minute  white  cicatrices.  The  other  variety 
of  this  follicular  eruption  consists  from  the  first  of  pustules 
which  are  small  and  pointed,  with  swollen  red  bases  ;  they 
may  be  present  in  immense  numbers,  not  only  on  the 
face,  but  also  on  the  chest,  trunk,  and  back. 

The  Papular  Syphilide 

is  known  as  the  "  Lenticular  Syphilide,"  and  consists  of 
red,  shiny  elevations,  which  feel  hard  and  shotty,  and 
vary  in  size  from  a  millet  seed  to  the  size  of  a  split 
pea.  They  develop  rapidly,  coming  out  in  a  few  days, 
and  develop  in  crops  ;  they  are  generally  scattered  irregu- 
larly over  the  body,  are  sometimes  numerous  on  the 
forehead  and  neck,  and  occasionally  appear  profusely  on 
the  face.  These  papules  remain  for  a  long  time,  some- 
times for  months,  when  they  gradually  decline  ;  at  other 
times  their  surface  or  summit  softens  and  becomes 
covered  with  a  brown  crust. 

This  eruption  is  of  two  kinds  :  the  small  fiat  papular 
syphilides,  and  the  large  flat  papules.  The  former  begin 
as  minute  red  spots,  which  rapidly  increase  in  size  until 
they  reach  a  diameter  of  perhaps  one-fourth  of  an  inch. 
They  are  round  or  oval.  The  papules  are  first  seen 
about  the  shoulders,  neck,  and  sides  of  chest,  and  later 
on  they  appear  on  the  forehead  at  the  margin  of  the 
scalp,  and  on  the  face,  chiefly  about  the  nose,  mouth, 
and  chin,  and  eventually  they  may  invade  the  trunk 
generally. 

The  large  fiat  papules  are  either  round  or  oval,  having 
a  diameter  of  an  inch  in  some  cases.     Their  surface  is 


54     SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

flat  and  covered  with  a  few  adherent  scales;  colour  red, 
becoming  coppery ;  they  are  very  chronic,  and  cause 
neither  pain  nor  itching. 

On  thick  cuticle,  like  that  of  the  palms  and  soles,  the 
spots  are  not  raised  into  papules,  but  form  round,  horny 
plates  with  copper-coloured  margins.  After  a  time  these 
plates  become  detached,  and  their  place  is  taken  by  thick 
crusts  or  scales,  or  an  ulcer  is  formed,  and  this  is  the 
condition  which  constitutes  "  syphilitic  palmar  or  plantar 
psoriasis."  The  early  appearance  of  this  syphilide  is  sup- 
posed to  be  the  herald  of  a  severe  form  of  syphilis. 

The  Squamous  Syphilide 

Generally  known  as  "  Syphilitic  Lepra,"  these  lesions  are 
flat  and  hardly  raised  above  the  surface  ;  they  are  covered 
with  silvery  scales,  underneath  which  is  a  coppery 
glistening  base.  The  scales  are  easily  detached,  but  ac- 
cumulate over  and  over  again.  This  eruption  is  rather  a 
late  one  ;  the  spots  are  always  scattered,  few,  and  confined 
to  one  particular  region  :  for  instance,  they  may  be  limited 
altogether  to  the  thighs  or  palms  of  the  hands  or  soles 
of  the  feet. 

The  Circinate  Syphilide 

A  particular  variety  of  this  eruption  is  the  "  Circinate 
Syphilide,"  which  is  fairly  common.  It  assumes  the  shape 
of  rings,  and  resembles  very  much  Tinea  Circinata ;  but 
the  exfoliation  of  the  margin  is  generally  profuse,  and 
the  silvery  scales  become  easily  detached ;  the  rings  are 
few  and  scattered,  their  favourite  site  being  the  front  of 


SECONDARY  PERIOD  55 

the  thighs,  but  they  may  appear  anywhere  from  the 
forehead  and  face  downwards.  This  eruption  is  very 
prone  to  relapse,  coming  out  as  late  as  the  fifth  year. 

The  Vesicular  Syphilide 

This  is  a  rare  variety  ;  the  vesicles  are,  as  a  rule,  small.. 
They  may  come  out  profusely  all  over  the  body,  or  in 
groups,  the  face  and  genitals  being  usually  the  selected, 
spots  ;  these  vesicles  are  filled  with  a  clear  fluid,  which 
generally  dries  up,  but  sometimes  they  become  pustular. 

The  Pustular  Syphilide 

These  syphilides  constitute  an  important  group,  which, 
though  less  common  than  the  erythematous  or  papular 
form,  may  appear  in  the  earlier  stages  of  syphilis  at  any 
time,  and  late  in  its  tertiary  period.  They  consist  of 
pustules  of  all  sizes,  each  of  which  is  seated  on  a  firm 
base  ;  they  may  be  present  in  immense  numbers,  especially 
in  the  face  and  trunk  ;  they  come  out  rapidly  and  in  suc- 
cessive crops,  accompanied  by  much  febrile  disturbance  ; 
they  relapse  even  after  a  year.  They  dry  up  into  brown 
or  black  scabs,  and  leave  large  stains,  which  ultimately 
pass  into  shallow,  flat  cicatrices.  In  other  cases  the 
inflamed  bases  continue  to  spread  long  after  the  summits 
have  scabbed  over  ;  thus,  as  the  crusts  increase  in  size 
the  older  parts  are  continually  being  pushed  up  by  the 
collection  of  fresh  material  underneath,  so  that  they 
assume  a  conical  shape  and  look  like  shells,  whilst  others 
acquire  enormous  sizes.  This  variety  of  eruption  is 
called  "  Rupia." 


56     SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

Some  Special  Varieties  of  Syphilide 

Besides  those  described,  other  forms  of  syphilides  are 
common — viz.  pigmentary,  acneform,  and  malignant  pre- 
cocious syphilides. 

The  Pigmentary  Syphilide 

This  is  seen  in  two  distinct  forms — viz.  in  spots  or 
patches  of  various  sizes,  or  as  a  diffuse  pigmentation  which, 
later  on,  becomes  the  seat  of  leucoderma  ;  this  latter  is  the 
retiform  pigmentary  syphilide. 

The  evolution  of  this  syphilide  may  occur  as  early  as 
the  third  month,  but  it  usually  appears  about  the  sixth,  or 
towards  the  end  of  the  first  year,  and  often  is  postponed 
until  the  second  or  third  year  of  infection.  It  occurs 
generally  in  women.  The  parts  of  predilection  are  the 
lateral  surfaces  of  the  neck,  face,  or  forehead. 

The  first  variety  of  the  pigmentary  syphilide  consists 
of  round  or  oval  plaques,  which  may  have  sharply  defined 
borders,  and  their  colour  is  light  brown. 

The  second  form — the  lace  form — is  much  more  common 
than  the  former ;  slowly  or  rapidly  the  neck  becomes 
discoloured,  the  tint  being  cafe-au-lait.  Scattered  irregu- 
larly over  the  pigmented  surface  are  irregular  or  oval 
white  spots,  which  gradually  enlarge  and  increase  in 
numbers  until  the  neck  is  covered  with  them  and  the  skin 
assumes  a  lace-like  character — hence  the  name. 

Other  Early  Secondary  Symptoms 

An&mic  alteration  in  the  blood. — Anaemia  is  generally 
a  marked  symptom,  for  even  before  the  enlargement  of 


SECONDARY  PERIOD  57 

the  lymphatic  glands  the  patient  becomes  pale,  listless, 
and  loses  weight,  and  is  evidently  gravely  debilitated ; 
there  is  a  general  "  impress "  about  him  which  is  very 
apparent  to  the  expert.  Examination  of  the  blood  shows 
deficiency  in  haemoglobin  and  red  cells  with  some  increase 
of  the  white.  These  changes  become  more  marked 
as  the  case  proceeds,  and  vary  in  intensity  with  the 
severity  of  the  disease. 

SYPHILITIC  AFFECTIONS  OF  THE  VARIOUS 
MUCOUS  MEMBRANES 

Erythema  of  the  mucous  membranes  is  usually  con- 
fined to  the  neighbourhood  of  the  fauces  and  to  that 
of  the  outlets  of  mucous  canals,  especially  around  the 
genital  organs  and  anus  and  the  mucous  membrane  of 
the  mouth.  The  most  common  syphilitic  lesions  of  the 
mouth  are  mucous  patches,  which  consist  of  greyish  white 
areas  termed  "  opaline  patches."  Their  site  is  generally 
the  angles  of  the  mouth,  inner  surface  of  the  cheeks  and 
dorsum  of  the  tongue.  They  occur  most  often  in  the 
mouths  of  inveterate  smokers,  and  are  due  to  proliferations 
of  the  epithelium  ;  they  are  sometimes  fissured  or  eroded, 
are  very  obstinate,  and  persist  long  after  all  signs  of 
the  infection  have  apparently  passed  away. 

Superficial  Affections  of  the  Tongue 

The  mucous  membrane  of  the  tongue  may  also  become 
hyperaemic  either  in  whole  or  parts  ;  when  the  latter  is  the 
case,  white  oval  patches  of  erythema  are  scattered  over  the 


58      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

dorsum.  From  these  the  epithelium  may  be  removed, 
leaving  an  eroded  or  perfectly  smooth  surface  forming  the 
well-known  "  plaques." 

Mucous  patches  of  the  tongue  are  very  frequent,  their 
usual  position  being  the  top  and  sides  of  the  organ. 
Smokers  are  particularly  liable  to  them.  Sometimes  the 
tongue  becomes  extensively  fissured  as  the  result  of  the 
erythema.  Mucous  patches  have  been  called  psoriasis  of 
the  tongue  and  leucoplakia.  They  are  usually  early 
visitors,  but  also  occur  in  the  secondary  stage  as  well  as 
in  the  tertiary,  and  when  late  in  the  latter  belong  rather 
to  the  parasyphilitic  affections  than  to  lesions  which  are 
the  outcome  of  direct  syphilitic  infection.  These  lesions 
are  very  prone  to  lead  to  epithelioma. 

Treatment  of  Mucous  Patches 

Patients  must  be  warned  as  to  the  danger  they  are 
to  others  when  suffering  from  these  lesions.  Smoking 
is  to  be  prohibited  altogether ;  the  morbid  spots  are  to 
be  sprayed  two  or  three  times  a  day  with  a  solution  of 
perhydrol  I  in  4,  or  nitrate  of  silver  5  grains  to  1  ounce. 
They  should  also  be  touched  daily  with  a  solution  of 
chromic  acid  5  grs.  to  the  ounce,  and  if  this  does  not 
improve  them,  one  of  20  grs.  to  the  ounce,  or  with  pure 
carbolic  acid.  The  mucous  membrane  of  the  mouth 
should  be  kept  as  healthy  as  possible  by  means  of  mouth 
washes  of  chlorate  of  potash,  borax,  perhydrol  or  carbolic 
I  in  40.  The  application  of  the  stronger  solutions  should 
only  be  made  at  intervals  of  two  or  three  days. 

Curetting  may  be  necessary. 


SECONDARY  PERIOD  59 

Syphilitic  Affections  of  the  NOSE 

The  nasal  mucous  membrane  may  be  the  seat  of 
erythematous  inflammation  with  consequent  ulceration, 
leading  very  often  to  increase  of  adenoid  tissue,  which 
latter  tends  to  blocking  up  the  nasal  passages  and  causes 
much  suffering. 

Treatment. — Strong  stimulating  applications  should  as 
a  rule  be  avoided  ;  spraying  frequently  with  mild 
solutions  of  boric  acid,  peroxide  of  hydrogen  or  per- 
hydrol  ;  insufflation  of  equal  parts  of  iodoform  and  boric 
acid. 

Mucous  Patches  of  Genital  Organs 

The  favourite  seat  of  these  is  the  anus  and  perinaeum, 
but  similar  patches  occur  near  the  angles  of  the 
mouth,  and  between  the  toes.  The  most  frequent  form 
they  assume  about  the  anus  is  that  known  as  con- 
dylomata, which  consist  of  broad  raised  patches,  edges 
well  defined,  surface  sometimes  dry,  but  much  oftener 
moist  and  coated  with  a  dirty  grey  secretion  which  gives 
off  a  sickly  smell.  The  lesions  consist  of  cell-infiltration 
of  the  cutis,  with  the  addition  of  overgrowth  of  the 
papillae  ;  they  sometimes  become  confluent,  and  then  a 
large  portion  of  skin  is  involved ;  and  occasionally  large 
cauliflower-like  excrescences  are  formed,  which  are  called 
vegetating  papules. 

Treatment. — Absolute  cleanliness  of  the  parts,  with  dry- 
ness, which  is  best  obtained  by  the  interposition  of  some 
absorbent  material;  black  or  yellow  wash  is  very  efficacious. 


60     SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

In  the  case  of  condylomata  these  lesions  should  be  destroyed 
with  fuming  nitric  acid  (nothing  is  better),  acid  nitrate 
of  mercury,  or  pure  carbolic  acid.  After  cauterisation  the 
surfaces  should  be  well  cleansed  and  dried,  and  dusted 
over  with  some  powder  such  as  starch,  boric  acid,  resorcin, 
or  calomel. 

Affections  of  the  LARYNX 

Erythema  of  the  larynx  may  be  so  slight  as  to  cause 
no  other  symptoms  than  slight  huskiness  with  moderate 
catarrh.  It  occurs  in  patches,  which  give  the  mucous 
membrane  a  mottled  appearance,  or  it  may  cause  diffuse 
redness.  Chronic  inflammation  of  the  larynx  is  common 
in  the  later  stages.  Early  laryngitis  usually  disappears 
rapidly  with  specific  treatment ;  but  locally  sprayings  of 
nitrate  of  silver  3  grs.  to  3  ij  are  good.  Should  ulceration 
be  present,  insufflation  of  iodoform  and  boric  acid  will  be 
found  excellent. 

Affections  of  the  HAIR 

Alopecia  is  a  common  and  early  symptom  of  syphilis  : 
there  may  be  either  total  or  partial  loss  of  hair.  The 
former  consists  of  a  general  shedding  of  the  hair,  causing 
total  baldness,  but  this  is  rare  :  more  commonly  the  shed- 
ding is  irregular,  and  hair  comes  out  in  patches,  leaving 
circular  bare  spots  ;  this  alopecia  may  attack  the 
moustache  and  beard.  As  a  rule  the  hair  grows  again 
rapidly,  unless  there  be  destruction  of  the  papillae,  when 
there  will  be  permanent  baldness. 

Treatment. — Hair  to  be  cut  quite  close  or  shaved  ;  daily 


SECOND AR  Y  PERIOD  6 1 

the  scalp  should  be  well  rubbed  with  an  ointment  of  white 
precipitate  (30  grs.),  cold  cream  (1  oz.) ;  parts  to  be 
thoroughly  washed  each  morning  with  soap  and  bran- 
water ;  a  lotion  of  bichloride  of  mercury  (1  in  1000)  to  be 
applied  twice  or  three  times  during  the  day. 

Secondary  Affections  of  NAILS 

Onychia — Secondary  affections  of  the  nails  are  of  two 
varieties — Onychia  and  Paronychia.  In  the  case  of  the 
former  the  nail  becomes  dry,  brittle,  and  breaks  on  little 
pressure  ;  its  surface  is  rough,  and  presents  longitudinal 
fissures  and  minute  depressions  in  which  dirt  collects,  and 
gives  the  nail  a  speckled  appearance.  The  epidermis 
under  the  free  margin  is   usually  thickened  and  scaly. 

Paronychia — Of  Paronychia  there  are  three  forms : 
ulcerative,  indolent,  and  diffuse.  The  ulcerative  form  may 
begin  as  a  papule ;  ulceration  of  this  takes  place,  and  extends 
along  the  sulcus  at  the  attached  border  of  the  nail ;  the  nail 
loses  its  lustre  and  becomes  detached,  and  from  beneath 
it  offensive  pus  exudes  ;  gradually  the  nail  is  undermined 
and  destroyed.  In  the  non-ulcerative  variety  the  border 
of  the  nail  is  thickened  and  infiltrated,  and  there  is  a 
papular  ring  round  it :  the  colour  is  dead  red  and  the 
surface  may  be  scaly.  The  nail  usually  loosens  and  drops 
off.  The  diffuse  form  begins  as  an  inflammation  or  rather 
hyperaemia  of  the  tissue  surrounding  the  nail.  At  first 
there  is  no  pain,  and  the  colour  is  dull  red,  which  as  the 
case  proceeds  becomes  coppery,  and  the  parts  become 
swollen  and  bulbous  ;  eventually  the  nail  itself  becomes 
engaged,  and  is  then  destroyed. 


62      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Treatment. — In  the  case  of  Onychia,  the  affected  finger 
should  be  soaked  frequently  in  a  solution  of  bichloride  of 
mercury  (i  in  iooo),  and  the  nails  kept  carefully  trimmed. 
In  ulcerative  Paronychia  the  diseased  surface  should  be 
exposed  as  soon  as  possible  and  cauterised  with  nitric 
or  chromic  acid,  and  water  dressings  applied,  followed  by 
the  application  of  iodoform.  Prolonged  immersion  of  the 
hand  in  a  warm  solution  of  bichloride  of  mercury  is  very 
beneficial. 

Secondary  affections  of  the  nails  generally  appear  within 
the  first  ten  years,  but  may  occur  very  much  later. 

Secondary  Affections  of  the  EYE 

Iritis. — Among  the  early  secondary  affections  of  the 
eye  iritis  takes  first  place,  and  it  is  of  two  kinds — simple 
plastic  iritis  and  parenchymatous  zritis.  Plastic  iritis  often 
occurs  about  the  second  month,  and  is  characterised  by 
severe  supra-orbital  pain,  worse  at  night,  and  by  con- 
tracted and  sluggish  pupils  ;  the  iris  is  discoloured  and 
adherent  to  the  lens,  and  there  is  vascular  injection  of  the 
cornea.  Parenchymatous  iritis  presents  yellowish  brown 
nodules  on  the  pupillary  border  of  the  inflamed  iris. 
The  nodules  are  very  distinct,  and  together  with  the 
ordinary  signs  of  iritis  go  to  form  true  syphilitic  iritis. 
This  variety  of  iritis  may  appear  like  the  plastic  in  the 
early  months,  but  may  be  delayed  to  a  much  later 
period. 

Treatment. — The  local  treatment  of  iritis  consists  mainly 
in  the  free  use  of  atropine,  a  solution  of  which  (gr.  v  to  5  j) 
should  be  dropped  into  the  eye  every  second  hour  until 


SECONDARY  PERIOD  63 

good  dilatation  is  brought  about.  Pain  may  be  relieved 
by  hot  compresses  over  the  eyes  and  the  application  of 
leeches  to  the  temple.  Subconjunctival  injections  of 
bichloride  of  mercury  may  be  necessary  in  obstinate  cases. 
Atropine  is  essential  in  the  treatment  of  iritis.  It  should 
be  ordered  at  the  beginning  and  persevered  with  during 
the  continuance  of  the  attack,  the  object  being  to  keep 
the  pupil  dilated,  and  by  so  doing  to  break  through  any 
adhesions  which  may  have  formed  between  it  and  the 
capsule  of  the  lens.  Also  it  always  relieves  irritation, 
and  by  paralysing  accommodation  places  the  eye  in  a 
state  of  rest.  Should  the  pupil  become  closed  by  the 
effusion  of  lymph  on  to  the  pupillary  margin  of  the  lens, 
an  iridectomy  should  be  done  when  inflammation  has 
subsided,  for  the  purpose  of  making  an  artificial  pupil 
and  preventing  a  recurrence  of  iritis. 

Other  Secondary  Affections  of  the  Eye 

Other  affections  to  which  the  eye  is  exposed  in  syphilis 
are  cyclitis,  choroiditis,  irido-choroiditis,  and  retinitis  ;  but 
these  are  not  common,  and  occur  generally  in  the  later 
stages. 

Secondary  Affections  of  the  Nervous  System 

The  secondary  nervous  affections  are :  neuralgia, 
cephalalgia,  paralysis  (especially  of  the  muscles  of  the 
eye  and  face),  hemiplegia,  paraplegia,  and  chorea. 

One  of  the  earliest  symptoms  of  secondary  syphilis  is 
neuralgia,  affecting  the  superficial  nerves  of  the  scalp, 
and  producing  the  well-known  phenomenon  of  "  nocturnal 


64      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

headache,"  which  consists  of  a  dull  pain,  beginning, 
especially  towards  sundown,  in  the  back  of  the  neck, 
running  to  the  top  of  the  head  and  perhaps  lasting  for 
hours. 

Cephalalgia  is  more  a  feeling  of  tension  than  of  actual 
pain.  It  is  generally  located  in  the  occiput,  and  nocturnal 
exacerbations  are  marked. 

Motor  paralysis  of  t/ie  muscles  of  the  eye  and  face  are 
common  even  early  in  syphilis,  and  are  usually  the 
result  of  compression  of  the  nerve-trunk  by  periostitis  in 
the  early  stages  and  gumma  in  the  later. 

Although  hemiplegia  and  paraplegia  are  generally 
classed  as  belonging  almost  exclusively  to  the  tertiary 
period,  that  they  occur  quite  early  in  the  secondary 
stage  oftener  than  is  thought  is  the  writer's  belief.  He 
has  met  with  two  cases  where  they  took  place  in  the  third 
month,  another  in  the  fourth,  and  several  occurred  in  the 
sixth  to  the  eighth  month  after  infection. 

K.  G ,  aged  fifty-two,  a  medical  man,  noticed  a  small 

papule  on  one  of  his  fingers  in  or  about  the  first  week 
in  February  1907 ;  this  persisted  for  about  a  month, 
when  it  passed  away.  The  question  as  to  its  being 
syphilitic  or  not  was  considered,  but  it  was  pronounced 
to  be  not.  Six  weeks  later  the  glands  in  the  axilla 
and  neck  became  enlarged,  but  no  rash  appeared.  At 
the  end  of  two  months  he  began  to  take  "  grey  powder " 
daily.  He  was  apparently  quite  well  until  the  morning 
of  April  25,  when,  endeavouring  to  reach  out  of  bed  to 
get  his  watch,  he  found  he  could  not  move  his  arm 
(right),  and  the  leg  of  the  same   side   was   in    a   similar 


SECONDARY  PERIOD  65 

condition.  This  patient,  under  energetic  specific  treatment, 
made  a  good  recovery,  regaining  the  full  use  of  both 
limbs. 

E.  T ,  a  soldier,  contracted  the  disease  in  March  1908. 

Hard  sore,  with  subsequent  adenitis  and  a  roseolar  eruption. 
Had  but  a  modified  treatment,  as  he  deserted,  and  was 
found  in  the  street  by  the  police  unable  to  walk.  He 
stated  to  me  that  he  had  not  suffered  from  any  pre- 
monitory symptoms,  but  that  after  a  drinking  bout  he 
found  himself  in  the  street  unable  to  walk.  This  occurred 
at  the  end  of  June,  three  months  after  infection.  Under 
treatment  this  man  regained  complete  use  of  his  legs, 
and  is  still  serving. 

H.  C ,  a  soldier,  contracted   the  disease  in  October 

1908.  The  primary  lesion  was  considered  to  be  a  "soft 
sore,"  and  he  had  no  specific  treatment.  On  waking  one 
morning  in  February  1909,  he  found  he  could  not  move  his 
right  arm  or  either  leg ;  he  passed  his  urine  and  fsces 
involuntarily.  Under  calomel  injections  he  made  a 
wonderful  recovery,  and  is  still  serving.  Practically  all 
the  cases  of  hemiplegia  and  paraplegia  which  have  come 
under  the  author's  notice  had  received  either  no  specific 
treatment  or  a  very  modified  form  of  it. 

Hemiplegia  is  due  to  endarteritis  or  thrombosis  of  the 
middle  meningeal  artery,  whilst  paraplegia  results  from 
meningitis  of  the  membranes  of  the  cord. 

A  variety  of  phenomena  depending  on  the  extent  of 
the  lesions  may  accompany  syphilitic  hemiplegia,  such 
as  paralysis  of  various  nerves,  aphasia,  optic  neuritis,  and 
epilepsy  ;  mental  depression  is  constant. 

5 


66      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Prognosis  and   Treatment 

The  prognosis  is  better  in  syphilitic  hemiplegia  or 
paraplegia  than  in  the  simple  form,  much  depending  on 
the  amount  of  specific  treatment  already  given,  and  on 
the  energetic  way  it  is  carried  out  after  the  onset  of  the 
paralytic  symptoms. 

Secondary  Visceral  Affections 

There  may  be  albuminuria  due  to  syphilitic  nephritis, 
pleural  effusion  from  pleuritis,  and  congestion  of  the  liver 
causing  jaundice. 

The  osseous  system  is  often  one  of  the  earliest  attacked 
by  syphilis.  It  begins  as  a  simple  periostitis,  running 
on  sometimes  to  inflammation  of  the  bone  itself.  The 
tibia,  clavicle,  sternum,  bones  of  the  cranium  and  the  ribs 
are  mostly  attacked,  and  in  the  order  named. 

Periostitis 

This  is  often  a  very  early  secondary,  coming  on 
sometimes  before  the  appearance  of  any  rash,  etc.,  but  it 
is  more  often  seen  between  the  sixth  and  ninth  month. 
It  is  a  subacute  affection  ;  it  appears  as  a  swelling  over 
one  of  the  bones  already  quoted,  which  is  elastic,  tender, 
and  painful.  The  pain  is  sometimes  intense,  especially 
at  night-time.  Under  treatment  this  lesion  will  generally 
subside,  leaving  no  trace  behind  it ;  but  often  the  bone 
itself  becomes  engaged,  when  the  inflammation  is  some- 
times followed  by  suppuration.  In  any  case  bony 
nodules  called  osteophytes  remain  at  the  seat  of  attack. 


SECONDARY  PERIOD  67 

Secondary  Affections  of  the  Joints 

The  secondary  lesions  as  far  as  joints  go  are  of  two 
kinds — acute  and  subacute.  The  acute  generally  attacks 
the  elbow  joints  both  at  the  same  time.  There  is  slight 
swelling  accompanied  by  severe  pain,  which  is  always 
intensified  at  night-time,  and  there  is  usually  a  marked 
rise  of  bodily  temperature,  which  may  reach  1040  F. 
The  subacute  variety,  which  is  far  more  common  than 
the  former,  very  often  attacks  one  knee  only.  There 
appears  a  swelling  of  the  joint  which  is  unaccompanied 
by  pain,  or  if  the  latter  does  exist  it  is  only  slight ; 
bodily  disturbance  and  pyrexia  are  insignificant,  and  it 
generally  ends  in  resolution  ;  the  amount  of  fluid  secreted 
is  usually  small.  A  peculiar  feature  of  this  variety  is 
the  intermittent  character  of  the  effusion. 

Rheumatoid  Pains  of  Secondary  Syphilis 

Some  of  the  most  constant  symptoms  in  the  early 
months  of  syphilitic  infection  are  pains  in  the  muscles, 
bones,  and  joints.  The  muscles  attacked  are  chiefly  those 
of  the  extremities,  whilst  the  joints  affected  are  the  ankle, 
elbow,  wrist,  and  phalanges.  These  pains  begin  at  sun- 
down, and  get  gradually  worse  at  night. 

Secondary  Affections  of  the  Tendons 

Teno-synovitis  may  come  on  at  an  early  stage,  and  is 
characterised  by  effusion,  tenderness,  and  swelling  along 
the  course  of  a  tendon.  Sometimes  it  is  limited  to  one, 
such  as  the  tendo  Achillis,  more  rarely  it  attacks  several 


68     SYPHILIS:    ITS  DIAGNOSIS  AND  TREATMENT 

at  the   same   time,  and   there  may   be   severe  pain  and 
tenderness  over  them. 

Treatment. — Little  can  be  done  locally  for  these  affections ; 
everything  depends  on  constitutional  treatment  Pain 
can,  of  course,  be  assuaged  by  the  usual  methods,  and 
when  very  severe  morphia  hypodermically  is  indicated. 

Secondary  Affections  of  the  Epididymis  and  Testicle 

As  secondary  affections  these  are  not  common.  When 
the  epididymis  is  attacked  the  lesion  appears  as  an  acute 
inflammation,  which  readily  subsides  in  resolution  under 
treatment.  Inflammation  of  the  testicle  itself  is  very 
rare  in  early  syphilis,  and  when  it  does  occur  it  follows 
the  course  of  ordinary  acute  orchitis,  resolution  being 
generally  the  result. 

Specific  Treatment 

In  speaking  of  the  treatment  of  all  secondary  affections 
it  is  presumed  that  specific  treatment  is  strictly  adhered 
to  in  all,  as  no  local  measures  will  avail  in  its  absence. 


CHAPTER   VII 

TERTIARY  SYPHILIS 

WHEN  not  exterminated  in  its  secondary  stage  syphilis 
passes  into  a  chronic  condition,  when  it  is  called  tertiary. 

Tertiary  syphilitic  affections  present  many  differences 
from  those  of  the  secondary  stage :  they  are  of  deep 
development,  of  compact  structure,  and  slow  growth  ; 
they  are  less  numerous  and  more  isolated  than  secondary 
lesions,  irregular  in  their  course,  and  much  more  deeply 
seated  and  destructive  in  their  tendency.  Secondary 
affections  have  a  tendency  towards  resolution,  tertiary 
ones  favour  progression.  The  viscera  are  rarely  attacked 
in  secondary  syphilis,  whereas  in  the  tertiary  stage  they 
suffer  deeply  from  a  chronic  infiltration  which  produces 
nodules  and  tumours  called  gummata. 

It  is  almost  impossible  to  write  a  clear  and  defined 
description  of  tertiary  syphilis,  as  each  case  differs  so 
much  in  the  mode  of  onset  and  progression.  In  some 
cases  what  we  know  as  tertiary  lesions  make  their  appear- 
ance as  early  as  the  third  or  fourth  month,  while  the 
roseolar  rash  is  still  present.  The  patient  appears  suddenly 
to  change  for  the  worse  ;  any  skin  lesions  present  ulcer- 
ate  and    suppurate,  these   ulcers  spread    over   the   body, 


70      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

and  the  patient  becomes  weak  and  cachectic.  In  other 
cases  tertiary  syphilis  manifests  itself  in  hemiplegia, 
paraplegia,  and  other  nervous  lesions,  and  generally  these 
cases  are  rapid  and  severe.  The  majority  of  tertiary 
syphilis  cases  occur  in  the  third  or  fourth  year  and  on- 
wards from  the  date  of  infection.  The  following  tissues 
and  organs  are  attacked  in  sequence :  the  skin,  nervous 
system,  osseous  system,  mucous  membranes,  and  viscera. 

Some  authorities  believe  that  tertiary  syphilis  is  not 
true  syphilis,  but  that  it  is  a  chronic  condition  left  behind 
by  the  active  disease  ;  seeing  that  the  tertiary  lesions 
may  co-exist  with  the  secondary,  this  belief  seems  illogical. 
The  discovery  of  Spirochceta  pallida  in  tertiary  lesions  points 
to  these  being  due  to  the  same  condition  as  secondary 
syphilis,  modified  no  doubt  by  the  attenuation  of  the  virus. 
It  has  been  proved  that  syphilis  can  be  reproduced  by 
inoculation  with  matter  taken  from  gummata  and  other 
tertiary  lesions. 

The  chief  causes  of  tertiary  syphilis  are  inadequate 
treatment,  overwork,  enervating  climates,  excesses  of  all 
kinds,  more  especially  alcoholism.  Malaria  is  also  a  very 
special  adjunct  to  tertiary  syphilis. 

Cutaneous  and  Subcutaneous  Affections 

Gummatous  syphilides  are  typical  of  tertiary  syphilis. 
The  perivascular  cell  infiltration  forms  an  inflammatory 
neoplasm  in  the  skin,  which  has  a  tendency  to  soften 
and  to  ulcerate.  Some  of  these  syphilides  become 
ulcerated  almost  from  the  commencement,  whilst  others 
ulcerate  at  one  part  and  heal  at  another. 


TERTIARY  SYPHILIS  71 

Simple  Gummatous  Syphilides 

The  gummatous  syphilide  is  of  two  kinds  :  simple  and 
ulcerative.  The  first  is  formed  by  dark  red,  copper- 
coloured  nodules  of  slow  evolution  ;  the  extending  margin 
of  this  syphilide  is  circinate  or  serpiginous.  After  healing, 
a  brown  macule  is  left,  followed  by  a  depressed  cicatrix, 
and  there  is  destruction  of  tissue  without  ulceration. 

Ulcerative  Gummatous  Syphilides 
These  syphilides  may  consist  of  a  number  of  nodules, 
which  eventually  coalesce,  or  of  a  single  large  nodule  with 
extensive  serpiginous  ulceration.  Progress  is  slow  and  pain- 
less, and  inflammatory  reaction  absent.  The  nodule  may 
undergo  resolution  without  any  treatment  ;  but,  on  the 
other  hand,  it  may  persist  for  years.  Generally  specific 
treatment  has  a  marked  effect.  Under  this  it  heals 
rapidly,  leaving  a  cicatrix  which,  at  first  pigmented,  ulti- 
mately becomes  a  white  depression  circular  or  annular 
in  shape. 

Subcutaneous  Gummata 
These  appear  as  nodules  in  the  hypodermic  tissue.  They 
are  hard,  painless,  and  freely  movable  at  first.  Later  on 
they  become  caseated  and  adherent  to  the  skin,  which 
they  perforate,  and  form  an  ulcer  with  the  characteristics 
already  described.  When  they  have  healed  depressed 
pigmented  cicatrices  remain. 

Treatment  of  Gummatous  Syphilides 

Specific  treatment  is,  of  course,  absolutely  necessary, 
but  much  can  be  done   locally  for  ulceration.     Dressings 


72      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

of  iodoform,  mercurial  ointments  (red  and  yellow  oxide 
or  white  precipitate)  are  very  good ;  also  perhydrol 
(Merck),  in  a  concentrated  solution,  applied  two  or  three 
times  a  day,  or  calomel  applied  in  powder  or  fumigation. 
It  is  in  these  gummatous  syphilides  that  iodide  of  potas- 
sium is  so  useful.  Iodipin  given  by  intramuscular  or 
subcutaneous  injection  is  of  much  benefit. 

THE  ALIMENTARY  SYSTEM 

Tertiary  lesions  of  the  lips  are  not  common,  but  they 
are  important  owing  to  their  liability  to  being  mistaken 
for  cancer,  and  vice  versd.  They  may  appear  as  a 
tubercular  formation  or  as  a  gumma.  The  former  is  very 
apt  to  relapse.  In  shape  it  is  usually  circinate,  and  may 
extend  so  as  to  involve  most  of  the  lip.  It  may  appear 
as  diffuse  infiltration,  the  mucous  membrane  of  the  lip 
becoming  swollen  and  red.  In  other  cases  this  lesion 
assumes  the  character  of  a  hard  circumscribed  gumma  in 
the  substance  of  the  lip.  This  may  be  taken  for  cancer, 
but  in  the  gumma  the  lymphatic  glands  are  not  enlarged  ; 
the  skin  over  this  gumma  may  ulcerate,  and  then  it  may 
be  mistaken  for  a  chancre. 

The  Tongue 

Gummatous  inflammation  attacks  the  tongue  with  great 
frequency,  in  numerous  forms,  and  at  any  time. 

Superficial  Glossitis 

This  sometimes  arises  in  habitual  smokers.  On  exami- 
nation the  tongue  is  found  to  be  swollen,  bright  red,  and 


TERTIARY  SYPHILIS  73 

indented  at  its  edges  with  marks  of  the  teeth.  The  dorsal 
surface  is  devoid  of  fur,  and  the  papillae  may  have  dis- 
appeared over  a  large  surface.  The  tongue  itself  is  freely 
movable,  and  can  be  protruded  to  its  normal  extent. 
Its  surface  is  moist,  tender  and  painful.  There  is  little 
induration. 

In  other  cases  the  lesion  consists  of  patches  of  round 
or  oval  shape  and  deep  red  colour;  they  are  slightly 
raised  and  indurated,  and  when  healed  leave  milk-white 
patches.  They  run  a  very  chronic  course,  and  are  painless 
throughout ;  sometimes  they  soften  and  give  rise  to  ulcers, 
fissures,  or  erosions. 

Sclerosing  Glossitis 

This  is  characterised  by  swelling,  most  marked  on  the 
dorsal  surface  of  the  tongue,  the  central  part  being  most 
frequently  affected.  Disappearance  of  the  papillae  gives  a 
smooth  appearance  to  the  mucous  membrane  covering 
the  affected  parts.  Fissures  and  ulcers  are  produced, 
the  former  radiating  outwards  from  the  central  raph6. 
The  course  of  this  lesion  is  also  very  chronic.  The 
lymphatic  glands  seldom  enlarge. 

Gummatous  Glossitis 

This  occurs  about  four  to  six  years  after  infection,  and 
the  gummata  may  be  either  superficial  or  deep.  The 
former  are  usually  situated  on  the  dorsum  of  the  tongue. 
They  are  small  nodules  projecting  into  the  mucous  mem- 
brane, where  they  can  be  felt  as  hard  bodies,  not  always  very 
well  defined.     Unaffected  at  first,  the  mucous  membrane 


74      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

covering  a  nodule  eventually  softens,  and  an  ulcer  is 
formed,  with  a  typical  "  washleather "  slough  as  its  floor. 
The  deep  gummata  may  lie  at  any  depth  in  the  tongue's 
substance.  They  occur  at  any  age,  and  are  often  found 
in  children,  but  generally  appear  in  middle  age.  They 
form  painless  indolent  swellings,  with  the  mucous  mem- 
brane covering  them  unaltered.  They  are  not,  as  a  rule, 
tender.  Sooner  or  later  they  soften,  the  mucous  mem- 
brane gives  way,  and  ulceration  takes  place.  Needless 
to  say,  this  is  a  very  chronic  and  obstinate  affection. 

Differential  Diagnosis 

Gummata  of  the  tongue  may  be  mistaken  for  either 
innocent  or  malignant  tumours.  The  points  of  distinction 
between  innocent  tutnours  and  gummata  are  these.  The 
former  are  often  polypoid,  the  latter  never ;  innocent 
tumours  are,  as  a  rule,  well  defined,  whilst  gummata 
are  not ;  the  former  are  generally  single,  gummata  more 
often  multiple ;  innocent  tumours  are  often,  gummata 
never,  lobulated. 

The  diagnosis  between  gummata  of  the  tongue  and 
cancer  turns  upon  the  following  differences :  Cancer  is 
nearly  always  single,  gumma  often  multiple.  The  former 
tends  to  attack  the  borders  of  the  tongue,  the  latter  as 
often  the  middle.  Cancer  often  forms  opposite  a  carious 
tooth,  whereas  gumma  has  no  connection  therewith. 
Cancer  is  usually  a  disease  occurring  in  patients  past 
middle  life ;  gumma  is  found  in  those  between  twenty- 
five  and  thirty  years  of  age.  The  tongue  in  gumma  is 
freely  movable,  whilst  its  mobility  is  impaired  in  cancer. 


TERTIARY  SYPHILIS  75 

The  microscope  and  history  will  also  furnish  help  in 
differentiating  between  the  two  affections. 

Fissures  and  Ulcers  of  the  Tongue 

may  occur  both  in  early  and  in  late  syphilis.  The  latter 
are  very  often  found  in  the  dorsum,  and  are  caused  by 
softening  of  the  gummata.  Ulceration  begins  as  a  small 
hole,  which  quickly  enlarges  by  the  giving  way  of  the 
infiltrated  tissue  surrounding  the  tumour.  A  cavity  is 
formed  with  sharply  cut,  ragged  undermined  borders 
and  sloughy  floor.  Symptoms  are  usually  singularly 
slight,  considering  the  condition  ;  the  patient  suffers  in 
many  cases  little  inconvenience  other  than  a  feeling  of 
thickness  of  the  tongue,  pain  being  practically  absent 
at  first,  though  sometimes  troublesome  while  ulceration 
is  proceeding. 

Treatment  of  Tertiary  Affections  of  the  Tongue 

One  thing  is  very  certain,  i.e.  that  smokers  suffer  much 
more  often  from  these  affections  than  non-smokers  ;  hence 
smoking  should  be  forbidden  altogether,  or  at  least  much 
curtailed,  and  in  fact  all  irritation  or  anything  likely  to 
facilitate  it  should  be  avoided,  hence  spirits  and  hot 
condiments  should  be  forbidden.  The  dentist  should  be 
visited,  to  have  the  teeth  examined  and  put  right  when 
required,  all  tartar  being  scraped  off.  It  goes  without 
saying  that  specific  treatment  is  all-important  in  these 
affections ;  the  writer  has  found  calomel  by  injection 
most  useful,  and  the  arylarsonates  especially  beneficial. 
Iodide  of  potash  is  also  essential. 


76      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Cracks  and  fissures  should  be  well  dried,  and  then 
painted  with  a  solution  of  either  chromic  acid  (gr.  x  to  3J) 
or  of  perhydrol  or  peroxide  of  hydrogen.  When  there 
is  much  inflammation  of  the  parts  the  following  application 


a 


de  to  the  ulcers  : 
Iod     

grs.  ij     = 

grm. 

0.41 

Potassi  iodidi 

grs.  xx   = 

grm. 

1-37 

Tinct  opii 

TtlV                = 

grm. 

0.31 

01.  menth.  pip. 

mv        = 

grm. 

0.31 

Glycerini      

ad  si       = 

c.c. 

•3° 

Solve  et  Misce 

The  Palate 

Gummatous  infiltration  affects  both  the  hard  and  the 
soft  palate  as  well  in  acquired  as  in  inherited  syphilis. 
It  begins  either  as  a  local  gummatous  mass  or  as  a 
diffuse  infiltration.  In  the  former  case  it  projects  from 
the  soft  palate  as  a  flattened  tumour,  which  is  at  first 
hard  and  elastic,  but  eventually  softens  and  breaks  down, 
leaving  a  gummatous  ulcer  behind.  The  diffuse  variety 
is  much  oftener  seen.  The  soft  palate  becomes  thickened 
and  congested ;  this  may  be  limited  to  a  part,  or  it  may 
involve  the  whole  arch  of  the  soft  palate.  Later  on 
softening  of  this  infiltration  and  ulceration  takes  place, 
and  the  ulceration  may  extend  to  the  velum  palati,  the 
uvula,  and  pillars  of  the  fauces,  and  through  the  entire 
thickness  of  the  soft  palate,  so  that  perforation  is  the 
result.  Perforation  causes  the  voice  to  become  nasal, 
and  fluids  regurgitate  through  the  nose.  When  the  per- 
foration is  small,  it  may  close  by  granulation  ;  when  it 
cicatrises,  the  palate  is  left  scarred  and  deformed. 


TERTIARY  SYPHILIS  77 

Differential  Diagnoses 

Differential  Diagnoses  will  have  to  be  made  between 
gummatous  infiltration  of  the  palate  and  lupus,  tubercle 
and  cancer. 

Lupus  runs  a  much  more  chronic  course,  and  creeps 
over  the  surface  of  the  palate,  whereas  the  syphilitic 
affection  begins  in  the  deeper  tissues.  Lupus  does  not 
affect  the  bone,  whereas  gumma  does. 

Tubercular  ulceration  is  shallower  than  syphilitic ;  it  is 
more  limited  in  extent,  and  has  sharply-cut  edges,  whilst 
its  base  is  red  and  more  granular.  The  lymphatic  glands 
in  its  neighbourhood  are  often  enlarged  in  tuberculous 
ulceration,  but  are  seldom  so  in  syphilis.  Tubercle 
very  rarely  leads  to  perforation,  the  contrary  being  the 
case  with  syphilis.  Tuberculous  ulceration  is  unaffected 
by  specific  treatment  or  potassium  iodide. 

Treatment 

Treatment  consists  in  arresting  the  ulceration  by  specific 
treatment  and  iodide  of  potassium.  Locally  the  palate 
should  be  frequently  sprayed  with  dilute  solutions  of 
iodine  or  perhydrol,  and  kept  as  clean  as  possible.  No 
surgical  procedure  should  be  undertaken  until  all  ulceration 
has  ceased. 

Tertiary  Affections  of  the  Pharynx 

The  pharynx  is  liable  to  the  same  syphilitic  mani- 
festations as  the  mouth.  In  some  cases  the  entire  soft 
palate  is  destroyed  by  ulceration :  necrosis  of  the  hard 
palate  occurs,  the  mouth,  nose,  and  pharynx  being  con- 
verted into  one  cavity.     In  others  the  ulcerative  process 


78      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

is  limited  to  the  border  of  the  velum  and  pharyngeal 
wall ;  adhesions  form,  and  divide  the  cavity  of  the  pharynx 
into  two  distinct  chambers,  one  communicating  with  the 
posterior  nares,  the  other  with  the  mouth. 

Tertiary  Affections  of  the  Larynx 

These  consistof  chronic  inflammation  leading  to  thicken- 
ing or  hypertrophy  of  the  mucous  membrane,  and  accom- 
panied by  superficial  ulcers  from  which  spring  vegetations. 
These  vegetations  may  be  of  such  a  size  as  to  impede 
respiration.  The  cords  may  also  become  much  thickened, 
causing  in  some  cases  complete  aphonia.  Later  on  deep 
ulceration  may  occur,  the  epiglottis  and  aryteno-epiglottic 
ligaments  being  destroyed.  These  ulcerations  are  liable 
to  be  mistaken  for  malignant  disease,  from  which  they 
differ  by  being  of  slower  growth,  non-painful ;  and 
whereas  in  cancer  the  submaxillary  glands  are  from  an 
early  date  infiltrated,  they  are  not  so  in  syphilis.  Gum- 
matous tumours  may  also  occur  as  a  tertiary  lesion  in 
the  larynx. 

The  Trachea 

In  tertiary  syphilis  the  trachea  is  subject  to  gummatous 
infiltration  and  connective  tissue  proliferation.  The 
former  leads  to  ulceration  and  necrosis  of  cartilage. 
The  healing  of  the  ulcers  may  leave  cicatricial  contraction, 
which  may  lead  to  either  complete  or  partial  contraction 
of  the  trachea. 

The  Lungs 

The  morbid  processes  of  syphilis  in  the  lungs  consist 
of  indurations   and  gummata,  which   occur  in  either  the 


TERTIARY  SYPHILIS  79 

middle  or  lower  lobes  rather  than  at  the  apices.  Fibrous 
bands  enclosing  islets  of  lung  tissue  are  formed.  The 
bronchi  in  relation  with  these  are  flattened  and  the 
alveoli  are  filled  with  exudation  containing  leucocytes 
and  desquamated  epithelial  cells.  The  pleura  is  often 
thickened  and  adherent  about  these  areas.  The  surface 
of  the  lung  is  puckered  and  furrowed. 

Gumma  of  the  lung  is  more  common  than  the  above 
condition.  The  gumma  may  be  deposited  in  any  part 
of  the  organ,  but  is  mostly  found  in  the  lower  lobes. 
Softening  takes  place  in  the  centre  of  the  mass.  The 
parts  around  may  be  thickened  by  proliferation  of  cells, 
and  around  the  whole  mass  there  is  always  a  zone  of 
indurated  tissue.  The  degeneration  of  the  centres  leads 
to  liquefaction  and  evacuation  of  the  fluid,  which  is  the 
cause  of  much  irritation  to  the  bronchi.  Cough,  dyspnoea, 
haemoptysis,  and  muco-purulent  sputum  may  all  be 
present,  but  the  tubercle  bacilli  are  absent  from  the  latter. 
In  all  lung  lesions  beginning  in  the  lower  lobes,  and  slowly 
progressing  without  fever,  syphilis  should  be  suspected. 

The  Liver 

Of  all  the  abdominal  viscera,  the  liver  is  the  most 
frequently  attacked  by  tertiary  syphilis,  the  conditions 
produced  being  (1)  amyloid  degeneration,  (2)  perihepatitis, 
and  (3)  hepatitis,  either  diffuse  or  gummatous.  The  first 
is  the  result  of  cachexia.  In  perihepatitis  there  is  thicken- 
ing of  the  capsule  with  adhesions  to  surrounding  parts. 
In  hepatitis  there  is  great  increase  in  the  connective  tissue, 
accompanied  by  shrinking  and  the  formation    of  fibrous 


80     SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

bands  ;  by  the  contraction  of  these  bands  the  liver  be- 
comes lobulated  and  nodular  on  the  surface,  so  that  a 
"  ploughed-up "  appearance  is  caused.  Gummata  are 
frequently  found  in  the  liver,  and  consist  of  a  central 
zone  of  yellow  matter,  a  middle  zone  of  fibrous  tissue, 
and  an  outer  of  dense  hepatic  tissue.  The  yellow  matter 
in  the  central  zone  is  often  absorbedj  when  it  is  replaced 
by  a  mass  of  fibrous  tissue,  which  causes  puckering  of  the 
surface  of  the  organ. 

Symptoms 

The  liver  may  be  enlarged,  irregular,  and  nodular. 
Pain  in  the  hepatic  region  is  common,  and  may  be  sharp 
or  dull  and  persistent.  In  perihepatitis  the  pain  may  be 
very  severe.  As  a  result  of  pressure  ascites  may  occur. 
Marasmus  is  often  present,  accompanied  by  albuminuria 
and  persistent  jaundice.  On  the  whole  the  symptoms  in 
tertiary  syphilis  of  the  liver  are  mild  and  not  at  all 
distinct,  so  that  the  disease  may  be  entirely  overlooked. 

Tertiary  Affections  of  the  Spleen 

These  may  consist  of  infiltrations,  either  interstitial  or 
gummatous.  The  former  begin  around  the  blood-vessels, 
producing  a  diffuse  connective  tissue  which  presses  on 
the  splenic  pulp  and  causes  contraction  of  the  organ. 
Gummata  occurring  in  the  spleen  are  small,  and  are 
sometimes  found  single,  whilst  at  other  times  they  may 
be  numerous.  When  freshly  formed  the  gummata  have 
a  reddish-grey  colour  ;  when  old  they  are  dry  and  of  a 
yellow  colour.  They  cause  contraction  of  the  splenic 
capsule. 


TERTIARY  SYPHILIS  81 

The  Stomach  and  the  Rectum 

Tertiary  affections  of  the  stomach  are  very  rare,  and 
there  are  no  regular  symptoms  which  are  pathognomonic 
of  them.  When  they  do  occur  they  consist  of  gummatous 
infiltration  of  the  walls. 

The  rectum  may  be  attacked  in  tertiary  syphilis  in 
three  ways  :  by  ulceration,  by  gumma  formation,  or  by 
the  development  and  contraction  of  fibrous  tissues.  All 
these  varieties  may  lead  to  stricture  of  the  gut.  Indurating 
oedema  complicates  all  three  ;  the  process  extends  to  and 
surrounds  the  anus  ;  the  walls  of  the  rectum  become 
thickened  and  ulcerated,  a  condition  which  ends  in 
stricture.  Ulceration  of  the  mucous  membrane  on  the 
surface  of  the  indurating  mass  very  often  leads  to  abscess 
and  fistula. 

The  Kidney 

The  kidney  is  liable  to  be  attacked  in  three  ways — by 
gummata,  by  interstitial  nephritis,  and  by  amyloid  disease. 
Gummatous  infiltration  of  the  kidney  is  rare,  and  is  usually 
associated  with  the  same  condition  of  other  organs,  such 
as  the  liver  and  spleen.  Nephritis  is  of  the  chronic 
interstitial  variety,  and  leads  to  the  granular  contracted 
kidney  presenting  the  usual  symptoms  of  that  condition. 
Amyloid  disease  is  the  commonest  renal  result  of  tertiary 
syphilis,  and  is  also  nearly  always  associated  with  amyloid 
degeneration  of  the  liver  and  spleen. 

Treatment. — In  these  affections  of  the  kidneys  mercury 
must  be  given  cautiously,  but  at  the  same  time  specific 

6 


82      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

treatment  must  be  carried  out  by  injection  either  of  the 
soluble  salts  or  of  one  of  the  amylarsonate  preparations, 
the  latter  being  very  applicable  in  such  cases. 

The  Muscles  and  Tendons 

Myositis  occurs  as  the  result  of  tertiary  syphilis  in  three 
forms :  the  hyperaemic,  the  chronic  infiltrative,  and  the 
gummatous  nodular.  Myositis,  when  chronic,  tends  to 
more  or  less  contraction  ;  pain  is  usually  of  a  dull,  aching 
character.  One  or  more  muscles  may  be  attacked  at  the 
same  time  ;  those  most  frequently  involved  are  the  flexors 
of  the  upper  extremity,  especially  the  biceps. 

Globular,  fusiform,  or  flat  gummatous  tumours  may 
occur  in  the  muscle.  When  superficial  they  become 
adherent  to  the  aponeurosis,  which  becomes  inflamed  and 
hypertrophies.  They  are  best  detected  when  the  muscle  is 
relaxed.  They  excite  little  pain,  their  chief  inconvenience 
being  interference  with  motion.  These  tumours  may 
undergo  softening,  break  down  and  form   deep  ulcers. 

Tertiary  lesions  of  tendons  take  the  shape  of  teno- 
synovitis, with  hyperaemia  of  the  sheath  and  serous  effusion. 
They  form  elastic,  often  fluctuating  tumours,  and  may  be 
painful.     Gummata  sometimes  form  in  tendons. 

Tertiary  Affections  of  the  Bursas 

In  tertiary  syphilis  the  patellar  bursas  are  frequently 
attacked  by  painless  gummatous  infiltration,  elastic  to 
the  feel.  It  very  often  becomes  inflamed,  softens  and 
breaks  down,  and  then  is  very  tedious. 


TERTIARY  SYPHILIS  83 

Tertiary  Affections  of  the  Bones 

The  tertiary  affections  of  the  bones  consist  of  osteo- 
periostitis, exostoses,  and  gummatous  infiltration.  The 
bones  most  frequently  attacked  in  osteo-periostitis  are 
the  tibia,  ulna,  clavicle  and  sternum,  also  the  bones  of 
the  cranium.  The  signs  of  this  lesion  are  ill-defined 
tumours  of  different  sizes,  adherent  to  the  osseous  tissue ; 
they  are  very  tender  to  pressure  and  very  painful,  especi- 
ally towards  evening.  As  a  rule  they  end  in  absorption 
and  undergo  resolution  ;  in  other  cases  inflammation  takes 
place ;  the  skin  becomes  adherent  to  the  tumour,  is 
reddened  and  thinned ;  softening  takes  place,  and  an 
opening  is  formed  ;  eventually  the  superficial  portion  of 
the  bone  becomes  necrosed  and  comes  away. 

Exostoses  are  the  result  of  eburnation  of  bony  tissue  ; 
when  this  takes  place  resolution  is  not  possible ;  the  node 
or  tumour  remains  stationary.  As  a  rule  these  lesions 
give  little  trouble,  but  sometimes,  when  situated  on  the 
internal  surface  of  the  cranial  bones,  they  may  cause 
convulsions,  epilepsy,  and  various  forms  of  paralysis. 

Gummatous  Osteo-Periostitis 

The  bones  most  frequently  attacked  are  those  of  the 
cranium,  where  one  or  more  nodes  are  developed ;  the 
bones  of  the  face  are  also  very  liable  to  be  attacked, 
especially  the  malar,  superior  and  inferior  maxillary  bones  ; 
the  first  symptoms  are  swelling  and  pain,  and  very  often 
the  whole  bone  is  destroyed.  The  vertebra  may  be  the 
seat  of  gummatous  osteitis,  when  a  condition  called  "  syphi- 
litic spondylitis "  is    formed.     This  gives   rise  to  various 


84     SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

symptoms,  according  to  its  localisation  :  when  the  vertebra 
in  the  cervical  region  are  attacked,  paralysis  of  all  four 
limbs  may  take  place  ;  when  in  the  dorso-lumbar,  paralysis 
is  limited  to  the  lower  limbs.  Syphilitic  disease  of  the 
vertebrae  differs  from  tuberculosis  in  not  causing  destruc- 
tion of  the  whole  body  of  the  vertebra,  hence  in  the 
former  there  is  generally  an  absence  of  angular  curvature. 

Joint  Affections 

{a)  Synovitis,  subacute  and  chronic ;  {b)  Gummatous 
deposits  in  the  synovial  membranes ;  (c)  Gummatous 
changes  primarily  in  the  bones ;  (d)  Spreading  to  the 
joint  from  the  surrounding  parts ;  (e)  Ankyloses. 

Synovitis  of  the  tertiary  period  is  markedly  subacute ; 
there  is  but  slight  pain  or  impairment  of  movement ; 
the  effusion  into  the  cavity  takes  place  slowly  and  is 
never  very  great.  A  marked  feature  is  the  tendency  of 
this  affection  to  become  stationary.  There  is  seldom  any 
suppuration  or  any  other  degeneration,  in  marked  contrast 
to  tubercular  affections  of  the  same  parts. 

Gummatous  arthritis  generally  attacks  the  knee-joint. 
It  begins  in  an  insidious  manner,  there  being  but  slight 
pain  and  but  little  effusion.  It  may  set  up  acute  arthritis, 
ending  in  complete  destruction  of  the  joint  and  leading 
to  ankylosis. 

When  the  gummatous  disease  begins  in  the  bones, 
osteitis  affects  both  the  epiphysis  and  the  diaphysis, 
causing  enlargement  of  the  bone  near  the  joint.  It 
is  frequently  preceded  by  nocturnal  pains,  though  later 
on  pain  is  but  slight. 


TERTIARY  SYPHILIS  85 

The  Fingers  and  Toes 

Dactylitis  syphilitica  is  a  condition  due  to  gummatous 
deposit,  which  may  begin  in  the  bones  and  periosteum, 
eventually  implicating  the  joints ;  or  it  may  commence 
in  the  subcutaneous  tissue  of  the  fingers  and  toes,  and 
also  may  extend  to  the  joints. 

In  the  former  case  the  disease  develops  slowly  as  an 
enlargement  of  one  of  the  fingers  or  toes.  The  skin  over 
it  becomes  stretched  and  swollen ;  pain  is  slight,  and  may 
be  completely  absent.  Only  one  phalanx  may  be  attacked 
at  a  time,  but  usually  two  or  more,  and  eventually  the 
whole  finger  or  toe  becomes  implicated.  The  fingers  are 
attacked  more  often  than  the  toes.  The  swellings  may 
remain  in  the  same  indolent  condition  for  a  long  time, 
and  then  the  gummatous  deposit  is  either  absorbed  or 
softened  and  discharged  through  a  sinus.  The  bone  is 
generally  left  permanently  deformed,  and  may  be  partly 
absorbed  and  shortened  or  thickened. 

The  Testes 

Affections  of  these  organs  consist  of  chronic  hyperplastic 
processes  of  the  body  of  the  testis  alone  or  of  its  cover- 
ings as  well.  This  lesion  begins  without  inflammation  or 
pain.  The  organ  is  uniformly  enlarged,  hard,  firm,  and 
less  sensitive  than  in  its  normal  state.  There  may  be  an 
accompanying  hydrocele.  The  testicle  may  sometimes  be 
found  to  contain  masses  of  induration,  which  form  projec- 
tions on  its  surface;  the  latter  may  coalesce  and  form  a 


86      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

hard  resistant  mass  which  may  remain  for  years,  or  soften- 
ing and  breaking  down  may  take  place  and  an  abscess 
cavity  be  left. 

Treatment. — Specific  treatment  of  course  is  necessary, 
and  without  it  little  can  be  attained  locally.  Strapping  the 
testicle  with  mercurial  plaster  and  tapping  a  hydrocele 
when  present,  may  be  used  as  adjuvants. 

THE  CIRCULATORY  SYSTEM 

Lesions  in  the  arterial  system,  inside  or  outside  the 
cranium,  are  invariably  present,  and  constitute  the  most 
important  pathological  element  in  all  cases  of  syphilis, 
endarteritis,  panarteritis,  peri-arteritis  and  endoperi- 
arteritis,  all  being  constantly  found,  sometimes  in  the  same 
subject.  The  arterial  changes  may,  in  rare  cases,  manifest 
themselves  before  the  end  of  the  first  year,  especially  in 
the  neighbourhood  of  the  base  of  the  brain,  but  usually 
they  are  delayed  till  after  the  third  year,  and  often  they 
do  not  give  rise  to  symptoms  till  a  much  later  period,  when 
they  may  end  in  atheroma  of  the  aorta,  aneurysms,  or 
aortic  regurgitation. 

Several  types  of  syphilitic  arteritis  are  recognised,  the 
best  marked  being  the  obliterative,  in  which  the  most 
advanced  changes  are  seen  in  the  inner  coat  of  the  vessel, 
constituting  the  condition  known  as  "Endarteritis  ob- 
literans." The  intima  is  thickened  sometimes  more  on 
one  side  than  the  other  ;  the  internal  elastic  lamina  usually 
remains  intact,  but  it  may  be  absorbed.  The  tunica 
adventitia  is  generally  found    infiltrated  with  round  cells 


TERTIARY  SYPHILIS  87 

and  the  vasa  vasorum  thickened.  The  tunica  media  is 
sometimes  also  affected,  and  when  this  takes  place  the 
muscle  cells  are  atrophied.  The  wall  of  the  artery,  being 
deprived  of  its  elastic  and  muscular  elements,  offers  less 
resistance  to  the  blood  pressure,  bulging  takes  place,  and 
an  aneurysm  is  formed.  Thickening  of  the  intima  causes 
anaemia  of  the  parts  supplied  by  the  affected  vessel.  The 
result  will  depend  on  the  localisation  of  the  latter,  and 
much  will  depend  on  whether  it  is  a  terminal  artery,  or 
if  there  is  collateral  circulation.  In  the  latter  case  there 
will  be  loss  of  or  diminished  function.  If  the  vessel  is 
situated  in  a  lower  limb  the  latter  will  be  weakened. 
Should  it  be  the  coronary  arteries  which  are  engaged, 
angina  pectoris  may  result ;  should  the  affected  vessel  be 
in  the  brain,  dizziness,  etc.  will  follow.  Obliteration  of  a 
terminal  artery  will  cause  arrest  of  function,  and  in  the 
case  of  the  cerebral  arteries,  softening  of  the  brain. 

Endarteritis  obliterans  is  characterised  by  a  prolifera- 
tion of  the  endothelial  tissue,  and  the  media  and  adventitia 
are  infiltrated  with  small  cells.  In  gummatous  periarteritis 
nodular  gummata  may  develop  in  the  adventitia,  produc- 
ing globular  swellings  which  may  attain  considerable  size. 
These  swellings  are  not  infrequently  found  in  the  cerebral 
arteries.  Endarteritis  obliterans,  when  it  attacks  the 
vessels  of  the  limbs,  may  cause  gangrene,  the  signs  of 
which  consist  of  pain  lasting  over  a  long  period  with 
perhaps  no  other  symptom  but  oedema.  Charcot  de- 
scribes a  peculiar  gait,  which  he  says  is  a  sure  sign  of 
arterial  constriction, — when  walking  there  is  a  sudden 
attack  of  numbness  and  weakness  accompanied  by  pain 


88      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

and  cramp  in  the  limb.  In  two  cases  which  occurred 
in  the  author's  practice,  the  first  symptoms  took  place 
in  the  cricket  field  :  the  patient  was  about  to  deliver  a 
ball  in  bowling  when  he  experienced  a  numbness  in  the 
calf  of  one  of  his  legs,  and  this  was  followed  by  sharp  pain  ; 
these  passed  away,  but  it  was  the  beginning  of  endar- 
teritis obliterans,  which  eventually  resulted  in  loss  of  the 
limb.  The  second  case  happened  to  a  tennis  player,  who, 
whilst  serving,  suddenly  experienced  pain  and  numbness 
in  the  right  arm,  which  recurred  fairly  frequently  after 
this,  and  was  put  down  as  a  "  tennis  elbow  "  ;  this  case  also 
ended  in  amputation  of  the  limb  about  two  years  later. 
In  endarteritis  obliterans  the  calibre  of  the  artery  is 
slowly  but  progressively  occluded,  until  it  is  completely 
so,  when  gangrene  sets  in,  resulting  in  the  loss  of  the 
affected  limb  or  part  of  it.  The  process  may  attack  one 
limb  after  another,  and  the  writer  remembers  one  case  in 
which  both  arms  and  both  legs  had  been  amputated  for 
endarteritis  obliterans. 

Atheroma 

Atheroma  is  a  secondary  degeneration  of  the  coats  of  an 
artery  brought  about  by  endarteritis  of  its  vasa  vasorum, 
causing  defective  nutrition  of  the  walls  of  the  vessel,  and 
by  the  toxic  effects  of  the  syphilitic  virus  itself  on  the 
vessel.  This  leads  to  what  is  known  as  atheroma  and  to 
endarteritis  deformans.  Of  the  many  causes  of  atheroma 
syphilis  is  the  most  important  There  is  a  local  syphilitic 
arteritis  most  commonly  seen  in  the  aota — aortitis  which 
is   a   prime   factor   in   the  production  of  aneurysm  ;  and 


TERTIARY  SYPHILIS  89 

there  is  a  late  diffuse  change,  comparable   to   the   para- 
syphilitic  lesions  of  the  nervous  system. 

Aneurysm 

As  a  cause  of  aneurysm  syphilis  stands  pre-eminent ; 
the  arguments  in  favour  of  this  being  the  case  are : — the 
frequent  coexistence  of  aneurysm  with  other  syphilitic 
lesions  such  as  cerebral  arteritis,  the  number  of  cases  of 
aneurysm  with  histories  of  syphilis,  and  the  frequency  of 
aneurysm  in  locomotor  ataxy,  which  is  now  known  to  be 
almost  solely  of  syphilitic  origin. 


CHAPTER  VIII 

AFFECTIONS   OF  THE   NERVOUS  SYSTEM 

The   nervous   system   in   tertiary    syphilis    is   nearly  as 

frequently  attacked  as  the  skin  and  mucous  membranes 

taken   together.      Nearly   three-fourths   of  all   spinal-cord 

diseases   are   due    to   it,   as   are   those   of   brain   disease. 

Syphilitic  nerve  affections  may  be  developed  as  early  as 

the  fourth  month,  and  as  late  as  the  twentieth  year  after 

infection.     Fournier's  figures  show  that  in  about  one-ninth 

of  all  cases  of  ordinary  cerebral   syphilis   the  symptoms 

of  hemiplegia  occur  during  the  first  year  of  the  disease, 

and   a   much   larger   percentage   of    spinal   cases    occurs 

before  the  expiration  of  this  early  period.     In  rare  cases 

described  as  "  malignant,"  cerebral  and  spinal  affections 

have   been   recognised   before   the   disappearance   of   the 

primary   induration   at   the    site   of    infection.      Nervous 

symptoms  are  especially  likely  to  appear  in  individuals 

of  the  neurotic  type,  and  chorea,  migraine,  neuralgia,  etc., 

are   common   in   the   history   of    such    persons.      Mental 

anxiety   and   strain,   sexual   and   alcoholic    excesses    are 

certainly  predisposing  causes,  and  last,  although  not  least, 

90 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM  91 

comes    "  insufficient   treatment,"   which   is    indeed  one  of 
the  main  factors  in  tertiarism. 

The  following  figures  speak  for  themselves  : 

Fournier's  statistics  of  100  cases  of  cerebral  syphilis  of  which  the 
previous  history  of  treatment  was  known 


After  thorough  treatment 
After  modified  but  insufficient  treatment 
After  seven  to  eighteen  months'  treatment 
After  one  to  six  months'  treatment . 

After  no  treatment 

After  treatment  by  iodides  exclusively     . 


5 

6 

10 

70 

4 

5 

100 


The  above  shows  that  5  Per  cent,  only  occurred  after 
thorough  treatment,  as  against  95  per  cent,  after  insuffi- 
cient treatment 

In  tertiary  syphilis  of  the  nervous  system,  the  latter 
may  be  affected  by  the  syphilitic  virus,  by  its  causing 
inflammation  of  the  membranes  or  blood-vessels  with 
subsequent  occlusion  of  the  latter ;  by  gumma  of  various 
parts  of  the  brain  ;  by  its  lowering  the  vitality  of  the  cells, 
laying  them  open  to  parasyphilitic  affections — general 
paralysis,  tabes  and  epilepsy.  Inflammation  of  the  mem- 
branes (meningitis),  generally  affects  the  base  of  the  brain 
and  may  extend  down  the  membranes  of  the  cord  ; 
gummatous  deposits  nearly  always  originate  in  the  mem- 
branes— they  are  generally  small,  and  are  scattered  round 
the  vessels,  and  are  of  a  greyish  red  colour ;  when 
occurring  in  the  substance  of  the  brain  they  are  usually 
an  extension  from  the  meninges.  At  other  times  the 
gummata  may  be  single  and  large,  in  which  case  they  are 


92      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

mostly  found  at  the  base  of  the  brain  ;  they  are  greyish 
yellow  in  colour.  Adhesions  form  between  them  and  the 
dura  mater,  which  may  be  much  thickened.  The  chief 
lesion  in  cerebral  syphilis  is  endarteritis,  which  causes 
narrowing  of  the  lumen  of  the  affected  vessels,  and  con- 
sequently deficient  blood  supply  to  the  parts  of  the  brain 
dependent  on  them  ;  should  they  become  completely 
occluded,  softening  of  the  brain  surface  takes  place.  The 
symptoms  of  cerebral  syphilis  will  vary  according  to  the 
part  of  the  brain  which  is  engaged,  thus,  when  the  lesion 
is  situated  in  the  convexity  of  the  brain  it  may  lead  to 
epilepsy,  disorders  of  the  mind,  and  paralysis ;  whereas, 
when  on  the  base,  paralysis  will  follow  from  implication 
of  the  nerves  at  the  base  of  the  brain.  There  are  no 
symptoms  which  can  be  described  as  pathognomonic  of 
syphilis  of  the  brain,  but  the  following  are  suggestive 
of  it  :— 

Epilepsy  occurring  at  middle  or  adult  life  without  loss 
of  consciousness  ;  aphasia  ;  paralysis  of  certain  muscles 
(ocular),  paralysis,  mental  disorders,  more  especially  loss 
of  memory,  hemiplegia,  and  general  loss  of  health.  Of 
these  hemiplegia  is  perhaps  the  most  common,  and  is 
due  to  endarteritis  of  the  middle  cerebral  artery,  but 
sometimes  to  the  pressure  of  gummata.  Syphilitic 
hemiplegia  as  a  rule  sets  in  suddenly,  although  it  may 
have  been  preceded  by  headaches,  numbness,  and  transient 
paresis  of  the  ocular  muscles ;  sensation  is  generally 
unimpaired,  and  it  may  or  may  not  be  associated  with 
mental  disorder. 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM  93 

Tertiary  Syphilitic  Affections  of  the  Spinal  Cord 

The  spinal  cord  is  one  of  the  most  favourite  sites  of 
tertiary  syphilis  ;  the  lesions  produced  being  the  result 
of  inflammation  and  some  degeneration,  probably  caused 
by  endarteritis.  Tertiary  syphilis  attacks  the  cord  in  a 
very  irregular  manner,  and  is  not  limited,  as  in  locomotor 
ataxy,  to  the  posterior  columns,  but  may  attack  any  other 
part,  or  all  the  systems  at  the  same  time,  and  is  very  often 
associated  with  syphilis  of  the  brain. 

As  in  the  brain,  so  in  the  cord,  tertiary  syphilis  may 
affect  the  membranes  alone,  the  cord  itself,  or  both 
together,  the  latter  being  most  often  the  case  ;  all  three 
membranes  are  usually  affected  together,  and  when  the 
cord  is  engaged  its  posterior  columns  are  the  favourite 
sites. 

The  symptoms  of  spinal  syphilis  vary  much  owing  to 
the  irregular  distribution  of  the  lesions,  and  consist  chiefly 
of  pain  along  the  spine — girdle  pain — accompanied  by 
motor,  sensory,  and  trophic  symptoms.  Later  on  paraplegia 
sets  in,  with  affections  of  the  bladder  and  rectum. 

The  principal  lesions  of  tertiary  syphilis  of  the  spinal 
system  are  meningitis,  myelitis,  and  meningo-myelitis. 
Meningitis  is  very  often  an  early  affection.  Myelitis  may 
be  acute  or  chronic  ;  the  former  sets  in  suddenly, 
with  acute  and  severe  pain  somewhere  about  the  dorso- 
lumbar  region,  followed  in  a  few  days  by  paraplegia; 
both  lower  limbs  become  totally  paralysed,  and  a  fatal 
termination  very  often  is  the  result.  Chronic  myelitis 
is   the   commonest   syphilitic   affection   of  the   cord,   and 


94     SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

commences  with  sensations  of  numbness  and  tingling  of 
the  feet,  followed  after  a  long  period  by  affections  of  the 
bladder  and  rectum.  Sometimes  incontinence  takes  place, 
at  others  retention  is  the  rule.  The  disease  is  slow  in  its 
progress,  but  eventually  the  lower  limbs  become  partially 
paralysed.  Knee-jerks  are  irregular,  being  more  marked 
on  one  side  than  the  other,  and  there  may  be  anaesthesia 
or  hyperesthesia  in  irregular  patches.  Cramps  in  the  legs 
are  also,  as  a  rule,  a  great  trouble.  The  disease  may  be 
arrested  in  its  progress,  but  such  cases  are  rare ;  the 
majority,  in  the  absence  of  early  treatment,  becoming 
hopeless  paralytics. 

Leucocytosis  of  the  Cerebro-spinal  Fluid 

Widal  and  Ravant  discovered  that  lymphocytosis  of  the 
cerebro-spinal  fluid  always  accompanies  organic  disease 
of  the  nervous  system,  more  especially  tuberculous  and 
syphilitic  meningitis,  as  well  as  tabes  and  general  paralysis, 
but  that  it  is  absent  in  functional  diseases.  Hence  they 
advocate  lumbar  puncture  in  all  cases  of  syphilis  with 
nervous  symptoms  ;  the  presence  of  lymphocytosis  being 
an  indication  for  energetic  treatment.  Undoubtedly  this 
is  a  valuable  means  of  diagnosis. 

Treatment  of  Cerebro-spinal  Syphilis 

The  treatment  of  cerebro-spinal  syphilis  must  be  com- 
menced as  soon  as  the  diagnosis  has  been  made.  To  be 
of  use  treatment  must  be  of  an  intensive  character, 
mercury  being,  as  usual,  our  sheet-anchor  ;  by  far  the 
best  form  to  administer  it  in    these  cases   is   by  calomel 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM  95 

injections.  Oral  administration  under  such  conditions  is 
practically  useless.  Failing  calomel  injections,  inunction 
a  l'Aachen  (Aix-la-Chapelle)  is  the  best.  I  have  seen 
many  cases  of  cerebro-spinal  syphilis  make  wonderful 
recoveries  under  these  injections.  My  plan  is  to  give 
gr.  I  of  calomel  by  intramuscular  injection  twice  a  week 
for  four  weeks,  then  to  suspend  the  treatment  for  a  period 
of  two  weeks,  and  then  repeat  the  course,  at  the  same 
time  being  guided  by  the  symptoms,  etc.,  as  to  continuing 
it  further.  During  the  intervals  iodide  of  potassium  ought 
to  be  given  in  not  smaller  doses  than  gr.  xv  three  times 
a  day,  and  for  not  longer  than  ten  days  at  a  time ;  the 
dose  being  gradually  increased  to  gr.  xxx.  three  times 
a  day. 


CHAPTER   IX 

PARASYPHILIS   OR   QUATERNARY  SYPHILIS 

MANY  years,  it  may  be,  from  the  primary  sore  and  from 
any  active  manifestations,  certain  diseases  may  follow, 
not  directly  syphilitic,  but  dependent  in  some  way  upon 
its  poison,  and  hence  termed  parasyphilitic  affections,  the 
chief  of  which  are  locomotor  ataxia,  general  paralysis,  and 
epilepsy.  Of  these,  Fournier  and  Mott  maintain  that 
tabes  and  general  paralysis  are  pathogenically  identical, 
and  only  different  aspects  of  the  same  disease.  Both  are 
caused  by  syphilis,  and  appear  about  the  same  time  after 
infection  ; — Argyll  "  Robertson  pupil "  and  lymphocytosis 
of  the  cerebro-spinal  fluid  are  common  to  both.  These 
authorities  also  say  that  the  primary  lesion  in  both  tabes 
and  general  paralysis  is  the  same,  being  a  dystrophy  of 
the  neurones,  the  sclerosis  and  thickening  of  the  mem- 
branes being  a  secondary  result  of  degeneration. 

Tabes  or  Locomotor  Ataxia 

Tabes,     tabes     dorsalis,    or    locomotor    ataxia,    is    an 

affection  characterised  clinically  by  sensory  disturbances, 

incoordination,  trophic  changes  and  involvement  of  special 

96 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS        97 

organs,  particularly  the  eye.  Anatomically  there  are 
found  degenerations  of  the  root  fibres  of  the  dorsal 
columns  of  the  cord,  of  the  dorsal  roots,  and  at  times  of 
the  spinal  ganglia  and  peripheral  nerves.  At  the  present 
time  tabes  is  looked  on  as  essentially  a  syphilitic  disease. 
Moebius  says,  "  The  longer  I  reflect  upon  it,  the  more 
firmly  I  believe  that  tabes  never  originates  without 
syphilis."  Erb,  Fournier,  and  Gowers  show  that  in  from 
50  to  90  per  cent,  of  all  cases  of  tabes  there  is  a  syphilitic 
history,  and  Erb's  latest  figures  show  that  of  three  hundred 
cases  of  tabes  89  per  cent,  had  a  history  of  this  disease. 

The  importance  of  the  role  played  by  syphilis  in  the 
production  of  tabes  and  general  paralysis  becomes  more 
and  more  evident  as  time  goes  on.  Collins  in  a  series  of 
140  cases  of  tabes  obtained  a  definite  history  of  syphilis  in 
70  per  cent,  of  them,  whereas  out  of  140  cases  of  nervous 
diseases  other  than  tabes  or  general  paralysis  only  8' 5 
had  had  syphilis.  Additional  proof  of  the  syphilitic 
origin  of  tabes  and  general  paralysis  is  afforded  by  the 
results  of  cyto-diagnoses  of  the  cerebro-spinal  fluid  by 
lumbar  puncture.  Widal,  Sicard,  and  Ravant  found 
distinct  lymphocytosis  in  36  out  of  37  cases.  Lympho- 
cytosis is  often  distinct  in  the  very  earliest  stage,  even 
preceding  "  Argyll-Robertson  pupil  "  or  loss  of  knee-jerks. 

Exciting  Causes. — Excessive  fatigue,  over-exertion, 
injury,  exposure  to  cold  and  wet,  all  no  doubt  contribute 
to  the  development  of  tabes. 

A  good  many  cases  are  on  record  of  the  existence  of 
the  disease  in  both  husband  and  wife,  and  a  few  where 
children  were  also  affected. 

7 


98      SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Theories  as  regards  Actual  Lesion. — Maries  and 
Guillain  believe  in  a  "  lympho-angiotic "  theory — that 
tabes  is  due  to  a  syphilitic  affection  of  the  posterior 
lymphatic  system  of  the  cord. 

Magrath  maintains  that  it  is  due  to  the  spread  of  a 
chronic  syphilitic  meningitis  to  the  posterior  roots. 

Ferrier  comes  to  the  conclusion  concerning  tabes  that 
the  most  feasible  hypothesis  is  that  its  essential  lesion  is 
a  dystrophy,  probably  toxic  in  origin,  affecting  the  sensory 
protoneurones  as  a  whole,  manifesting  in  degeneration 
of  its  intraspinal  prolongations,  and  that  the  toxin  in 
tabes  is  generated  by  the  syphilitic  virus.  The  toxin  of 
syphilis  differs  from  others  inasmuch  as  the  disease  is  a 
progressive  one,  and  does  not  tend  to  come  to  a  standstill, 
as  in  other  toxin-produced  degenerations. 

Purves  Stewart  shows  that  lymphocytosis  of  the 
cerebro-spinal  fluid  is  constantly  present  both  in  tabes 
and  general  paralysis  from  the  very  start,  and  is  un- 
influenced by  the  most  energetic  anti-syphilitic  treat- 
ment, unlike  other  lesions  of  the  central  nervous 
system. 

Ford  Robertson's  Theory. — Another  theory  concerning 
tabes  is  that  of  Ford  Robertson,  who  says :  "  We  have 
found  that  bacilli  of  the  diphtheroid  group  can  be  found 
to  be  invading  the  tissues  in  all  cases  of  advancing  tabes 
and  general  paralysis  ;  the  chief  seats  of  invasion  are  the 
naso-pharyngeal  and  oral  mucosae  in  cases  of  general 
paralysis  and  the  genito-urinary  tract  in  tabes."  He  has 
named  the  bacillus — bacillus  paralyticans.  He  further 
states  that  he  has  seen  cases  of  general  paralysis  and  tabes 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS        99 

much  benefited  by  anti-bacterial  serum  prepared  in  the 
sheep  by  immunisation  with  these  special  diphtheroidal 
cells. 

Symptoms. — In  typical  cases  there  are  three  stages  of 
the  disease — the  pre-ataxic,  the  ataxic,  and  the  paralytic 
stages.  In  the  pre-ataxic  stage  the  chief  symptoms  are 
pains,  ocular  symptoms,  bladder  symptoms,  trophic  dis- 
turbances, and  loss  of  deep  reflexes. 

Pains,  usually  of  a  sharp,  stabbing  character — hence 
the  term  "  lightning  pains."  They  last  only  a  second  or 
two,  and  are  most  common  in  the  legs  or  about  the  trunk  ; 
they  dart  from  place  to  place.  At  times  they  are  of  a 
burning  character,  and  when  they  disappear  leave  the  areas 
they  occupied  tender  to  pressure.  They  occur  at  irregular 
intervals,  and  are  prone  to  follow  excesses  of  all  kinds, 
exposure  to  cold  and  damp,  and  to  come  on  when  the 
health  is  impaired.  In  rare  cases,  as  pointed  out  by 
Gowers,  these  pains  may  constitute  the  only  symptom 
of  the  disease. 

Recently  the  writer  has  had  experience  of  three  cases 
of  tabes  where  lightning  pains  and  "  Argyll-Robertson 
pupil "  had  been  the  only  symptoms  in  periods  varying 
from  ten  to  seventeen  years. 

Ocular  Symptoms  consist  of — (a)  optic  atrophy ;  (b) 
ptosis  ;  (c)  paralysis  of  the  external  muscles  of  the  eye ; 
id)  "  Argyll-Robertson  pupil,"  in  which  there  is  loss  of 
the  iris  reflex  to  light ;  but  the  power  of  contraction  is 
demonstrated  when  a  patient  looks  at  a  near  object — 
accommodation.  The  pupils  are  generally  contracted, 
sometimes  to  a  pin-point. 


ioo    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Bladder  Symptoms, — The  first  warning  of  the  onset 
of  the  disease  may  be  a  certain  difficulty  in  emptying 
the  bladder.  In  many  cases  of  tabes  the  sexual  desire 
is  very  often  increased  early  in  the  disease,  but  rapidly 
becomes  diminished,  and  later  on  is  totally  abolished. 

Trophic  symptoms,  although  belonging  mostly  to  the 
later  stages,  very  often  occur  in  this,  the  incipient  stage, 
when  it  is  not  uncommon  to  find  a  perforating  ulcer 
of  the  foot. 

Loss  of  Deep  Reflexes. — One  of  the  most  reliable 
signs  of  tabes  is  diminution  or  absence  of  the  knee-jerks 
(Westphal's  sign),  and  this  early  and  most  important 
symptom  may  occur  years  before  ataxia  appears  ;  also  loss 
of  ankle  jerks.  The  combination  of  loss  of  either  of  these 
with  one  or  more  of  the  symptoms  mentioned  above, 
especially  with  lightning  pains  or  "Argyll-Robertson 
pupil,"  is  practically  diagnostic. 

Tabes  may  never  progress  beyond  this  stage.  A 
peculiarity  is  that  when  optic  atrophy  comes  on  early, 
ataxia  rarely  supervenes. 

Ataxic  Stage. — Ataxia  develops  gradually ;  one  of  the 
first  indications  of  it  is  the  patient's  inability  to  get  about 
in  the  dark,  or  to  maintain  his  equilibrium  when  washing 
his  face  with  his  eyes  shut. 

When  the  patient  stands  with  the  feet  together  and  the 
eyes  closed,  he  sways  and  loses  his  balance  (Romberg's 
sign).  He  cannot  stand  on  one  leg,  and  is  unable  to 
start  off  promptly  at  the  word  of  command.  On  turning 
quickly  he  is  apt  to  fall.  Gradually  the  characteristic 
gait   of  ataxia  comes  on  :   the   patient   starts  unsteadily, 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS      101 

with  his  legs  somewhat  apart,  lifting  his  foot  too  high 
and  jerking  out  the  limb,  which  comes  down  with  a 
sudden  stamp  caused  by  the  entire  sole  striking  the  ground 
at  once.  The  incoordination  is  not  limited  to  walking,  but 
extends  to  the  performance  of  other  movements  :  if  the 
patient,  whilst  in  the  recumbent  position,  is  asked  to  touch 
one  knee  with  the  other  foot,  the  irregularity  of  the 
movement  is  very  marked.  Incoordination,  although  less 
observable  in  the  upper  limbs,  is  very  often  evident,  as 
instanced  by  the  difficulty  which  the  patient  experiences 
in  buttoning  his  coat  or  collar.  There  is  no  paralysis, 
and  the  muscle-reactions  are  normal ;  but  the  subject  of 
ataxia  is  unable  to  co-ordinate  his  muscles  harmoniously. 

Sensory  symptoms  increase  as  the  case  goes  on  ;  the 
lightning  pains  come  on  oftener  and  persist  longer.  Other 
symptoms  are  tingling  and  "  pins  and  needles "  in  the 
feet,  with  areas  of  anaesthesia  and  hyperesthesia  ;  a  feeling 
as  if  a  layer  of  cotton  wool  were  interposed  between  the 
soles  of  the  feet  and  the  ground ;  "  pins  and  needles  "  in 
the  arms  and  hands.  A  frequent  and  constant  symptom 
is  a  feeling  of  "  bands  "  about  the  chest  and  waist,  giving 
the  sensation  of  something  heavy  tied  round  the  chest. 
A  well-marked  phenomenon  is  the  loss  of  ability  to 
localise  pain  :  if  the  patient  is  pricked  in  one  limb  he 
may  say  he  feels  it  in  the  other.  Reflexes  diminish  still 
further  in  this  stage,  and  the  eye  symptoms  become  more 
marked  ;  at  the  same  time  ataxia  is  very  rare  when 
optic  atrophy  exists. 

In  this  stage  the  visceral  symptoms  are  most  remarkable, 
and    consist   of    what    are    called    tabetic    crises,   severe 


102    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

paroxysms  of  pain  referred  to  various  viscera — laryngeal, 
gastric,  nephritic,  rectal,  and  urethral.  Gastric  crisis  is 
the  most  common,  there  is  intense  pain  in  the  stomach 
and  vomiting  of  acid  gastric  juice ;  the  attack  may 
come  on  suddenly  and  last  for  some  days.  Paroxysms 
of  pain  in  the  rectum,  accompanied  or  not  by  tenesmus, 
are  common. 

Trophic  Symptoms. — Trophic  changes  are  marked : 
sweating,  shedding  of  the  nails  and  teeth,  herpes,  and 
cedema.  The  perforating  ulcer  of  the  foot  is  a  most 
characteristic  phenomenon,  commencing  as  a  suppurating 
corn  under  the  prominence  of  the  first  or  fifth  toe.  The 
ulcer  gradually  eats  its  way  through  to  the  dorsum  of 
the  foot.  It  is  in  this  stage  that  the  condition  known 
as  Charcot's  joint  is  to  be  seen  :  a  huge  painless  swelling 
suddenly  appears  about  the  joint,  such  as  the  hip  or  knee, 
and  in  a  few  days  may  have  altogether  disappeared  or 
suppuration  taken  place,  with  total  disorganisation  of  the 
joint ;  this  affection  is  very  like  chronic  arthritis  deformans. 

The  Third  or  Paralytic  Stage.  —  In  this  all  the 
symptoms  deepen  ;  progress  is  very  slow  as  a  rule. 
Ataxia  becomes  so  marked  that  the  patient  is  unable  to 
stand,  and  later  on  he  becomes  quite  bed-ridden.  Incon- 
tinence or  retention  of  urine  sets  up  bladder  or  kidney 
mischief,  which  very  often  carries  him  off  if  pneumonia 
or  cerebral  apoplexy  are  not  beforehand.  The  courses  of 
the  symptoms  and  duration  of  tabes  are  most  variable  : 
one  patient  may  become  hopelessly  ataxic  in  a  twelve- 
month, whereas  another  may  be  able  to  walk  about  and 
attend  to  his  business  for  twenty  or  thirty  years. 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS      103 

Diagnosis. — The  presence  of  lightning  pains  when 
combined  with  any  of  the  other  signs  is  very  distinctive, 
and  the  combination  of  any  of  the  following  signs  is 
almost  pathognomonic  of  tabes — i.e.  absence  of  knee-jerk, 
"  Argyll-Robertson  pupil,"  lightning  pains,  visceral  crises, 
atrophy  of  the  optic  disc,  and  Romberg's  sign,  and  last, 
although  not  least,  a  history  of  syphilis.  Wasserman's 
reaction  test,  together  with  cyto-diagnosis,  may  be  of 
great  value  in  doubtful  cases. 

Prognosis. — Complete  recovery  cannot  be  expected, 
but  arrest  of  the  process,  with  a  marked  amelioration  of 
symptoms,  is  frequent.  On  the  whole  the  prognosis  of 
tabes  is  bad. 

Treatment. — In  treating  tabes  our  object  ought  to  be 
to  arrest  its  progress  and  relieve  symptoms,  as  we  can 
never  hope  to  restore  to  their  normal  condition  the 
degenerated  columns  of  the  cord.  For  this  purpose  anti- 
syphilitic  remedies  are  all-important  ;  the  treatment  should 
be  intensive,  and  for  this  purpose  nothing  is  better  than 
intramuscular  injections  of  calomel,  next  to  which  comes 
inunction  of  mercury  a  V Aix.  Iodides  given  in  inter- 
mittent courses  in  not  less  than  50  grains  per  day,  and 
continued  for  not  longer  than  ten  days  at  a  time,  are 
very  often  very  beneficial.  Lightning  and  other  pains 
are  best  relieved  by  phenacetin,  antiebrine,  or  antipyrine  ; 
and  gastric  and  other  crises  by  hypodermic  injections 
of  morphia. 

Bladder  symptoms  require  constant  care ;  when  the 
organ  cannot  be  perfectly  emptied  the  catheter  should 
be  used. 


104    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

GENERAL   PARALYSIS 

Like  tabes,  general  paralysis  is  undoubtedly  due  to 
syphilis  in  at  least  90  per  cent,  of  cases.  It  occurs  usually 
about  the  ages  of  thirty  to  thirty-five,  and  among  those 
who  live  an  active,  busy  life — hence  is  particularly  liable 
to  occur  among  active  business  men  in  large  cities. 
Fournier  maintains  that  the  chief  factor  in  the  causation 
of  general  paralysis  is  insufficient  treatment  of  syphilis. 
The  predisposing  causes  are  over-exertion  and  alcoholic 
and  sexual  excesses. 

Symptoms. — These  vary  very  much  ;  in  some  cases  the 
mental  and  in  others  the  motor-spinal  or  motor-cerebral 
symptoms  predominate.  The  disease  has  been  divided 
into  certain  stages,  but  these  are  ill  defined,  as  the 
symptoms  supposed  to  be  peculiar  to  a  particular  stage 
may  appear  at  any  period  of  the  malady.  The  im- 
portance of  recognising  the  very  earliest  signs  cannot 
be  exaggerated. 

Prodromata. — There  may  be  some  slight  change  in 
character  which  is  often  in  the  nature  of  an  exaggeration 
of  some  peculiarity  present  in  the  individual :  if  he  has 
been  always  quick  in  his  temper  he  now  shows  unusual 
irritability  ;  his  power  of  concentration  may  be  weakened, 
or  some  feebleness  may  be  noticed  in  his  will.  His 
affections  may  undergo  some  change,  and  moral  perver- 
sions of  various  kinds  may  be  noticed  by  his  performance 
of  acts  which  he  formerly  regarded  as  discourteous,  dis- 
honest, or  indecent  in  others.  Such  acts  may  be  first 
observed  to  occur  after  a  dose  of  alcohol  which  formerly 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS      105 

had  no  effect  upon  his  mental  equilibrium.  These  fore- 
shadowings  deepen  into  the  symptoms  of  the  real  disease, 
any  of  which  latter  may  also  appear  as  the  first  warning 
to  his  immediate  friends  :  thus  his  premonitory  symptoms 
may  be  those  of  an  abnormal  idea  of  his  own  importance, 
wealth,  and  station  ;  or  indifference  to  business.  Motor 
symptoms  or  restlessness,  slight  tremors  of  the  lips  and 
hands,  difficulty  in  articulation  or  in  letter-writing,  may 
precede  the  mental  warnings  ;  pupillary  rigidity  or  an 
unsteadiness  in  his  gait  may  be  the  first  sign  that  anything 
is  wrong. 

Mental  Symptoms  of  the  Established  Disease. — 
These  consist  of  the  exaggeration  of  the  "  warning 
symptoms  "  ;  the  character  of  the  patient  becomes  rapidly 
changed,  he  gets  heartless  and  careless  about  his  family 
and  home  duties,  neglects  his  business — though  his  mind 
may  be  filled  with  schemes  for  making  colossal  fortunes — 
and  he  may  take  to  the  spending  of  money  lavishly,  and 
may  at  the  same  time  not  scruple  as  to  how  he  obtains 
more.  His  will-power  is  markedly  weakened  ;  memory 
fails  early,  especially  for  recent  events ;  he  becomes 
unable  to  calculate,  and  may  soon  cease  to  remember 
the  day  of  the  week  or  the  number  of  the  year.  Rest- 
lessness is  marked,  and  there  is  a  liability  to  violent 
outbursts  of  anger  and  jealousy,  or  to  the  performance 
of  some  indecent  act. 

As  the  mental  deterioration  increases  towards  dementia, 
delusions  are  common,  the  most  characteristic  type  of 
which  is  the  "  grandiose,"  the  patient  fancying  himself 
God,    a   king,  or  the  possessor  of  boundless  wealth  :    on 


106    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

the  other  hand  these  grandiose  ideas  may  be  replaced 
by  depression  of  spirits  and  melancholia ;  the  patient 
often  has  the  delusion  that  all  food  is  poison,  or  else 
that  it  will  "  block  up "  his  intestines. 

Motor  Symptoms. — The  facial  muscles  are  generally 
the  first  to  show  the  serious  nature  of  the  disease.  The 
face  is  flabby  and  expressionless,  giving  the  idea  of 
stolidity ;  in  speaking  there  is  a  marked  tremulous  con- 
dition of  the  muscles,  which  show  want  of  control ; 
the  lips  and  tongue  are  the  seat  of  marked  tremor  ;  the 
tongue  is  protruded  with  difficulty  and  only  with  ataxic 
jerkings,  and  later  on  it  is  completely  paralysed. 
Speech  is  markedly  affected  ;  it  becomes  halting,  slow 
and  drawling.  The  prominence  of  the  cheeks  is  often 
noticed. 

Handwriting. — Letters  are  unevenly  formed,  the  strokes 
showing  shakiness  and  unequal  degrees  of  length  and 
strength ;  but  the  most  characteristic  feature  is  the 
omission  of  letters,  syllables,  or  complete  words. 

"  Argyll-Robertson  pupil "  is  marked  in  almost  every 
case.  The  knee-jerks  are  also  affected,  being  either 
exaggerated  or  the  reverse.  The  movements  of  the 
limbs  may  be  abnormal ;  the  gait  becomes  unsteady,  and 
may  be  typically  tabetic,  at  other  times  it  may  be  spastic. 

In  general  paralysis  there  is  a  liability  to  paralytic 
seizures,  which  have  a  tendency  to  recur  at  short  intervals, 
the  patient  being  left  hemiplegic,  monoplegic,  or  aphasic. 
These  paralytic  symptoms  usually  pass  off  in  a  few 
hours,  but  each  succeeding  attack  leaves  a  deepening  of 
the  mental  weakness  and  muscular  feebleness. 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS      107 

Sensory  Symptoms. — These  may  consist  of  partial 
or  total  blindness,  whilst  the  senses  of  smell  and  taste 
may  also  be  lost ;  illusions  and  hallucinations,  such  as 
seeing  faces  or  hearing  noises,  are  common.  Symptoms 
pointing  to  the  connection  between  general  paralysis 
and  tabes  are  frequent — e.g.  Charcot's  joint  affection, 
perforating  ulcer,  and  spontaneous  fracture  of  bones. 
Many  authorities  regard  the  essential  features  of  tabes 
and  general  paralysis  as  identical,  depending  altogether 
on  whether  it  be  the  cord  or  brain  which  is  the  seat  of 
the  process  of  degeneration. 

Course  and  Duration. — The  general  average  of  cases 
run  their  course  towards  total  dementia  and  death  within  a 
period  of  three  years,  and  in  rare  cases  a  couple  of  months. 
The  ordinary  course  is  that  as  the  patient  proceeds  to- 
wards complete  dementia  the  paralytic  symptoms  deepen, 
he  becomes  bed-ridden,  and  is  unable  to  articulate,  the 
sphincters  fail,  and  huge  bed-sores  form ;  he  usually 
succumbs  to  some  intercurrent  affection,  such  as  cystitis, 
diarrhoea,  or  general  inanition. 

./Etiology. — The  same  theories  as  to  the  pathogeny 
of  tabes  are  held  concerning  general  paralysis  ;  the  most 
likely  being  that  the  syphilitic  toxin  has  so  diminished 
the  natural  vitality  or  resistance  of  the  entire  nerve 
system  that,  certain  tracts  being  exposed  to  "over- 
exertion," their  nerve  elements  succumb  to  degeneration — 
a  view  which  is  supported  by  the  fact  that  the  disease  is 
always  more  advanced  in  the  cortex  of  the  frontal  lobes. 

Prognosis. — The  prognosis  of  general  paralysis  is  bad  ; 
indeed,  the  affection  may  be  looked  on  as  incurable. 


108    SYPHILIS:    ITS  DIAGNOSIS  AND  TREATMENT 

Treatment. — Nothing  really  can  be  done  either  to 
arrest  or  cure  general  paralysis,  although  if  recognised 
very  early  anti-syphilitic  measures  should  undoubtedly 
be  given  a  chance. 

EPILEPSY 

The  third  parasyphilitic  affection  to  be  considered  is 
epilepsy,  which  is  of  frequent  occurrence  in  cerebral 
syphilis,  and,  like  the  non-specific  variety,  presents  two 
forms — the  "  grand  mal  "  and  the  "  petit  mal."  Headache, 
increasing  in  severity,  always  precedes  an  attack  of 
syphilitic  epilepsy.  The  epileptic  aura  and  cry  are 
absent  as  a  rule.  The  attacks  occur  at  intervals,  and 
frequently  with  regularity  every  ten  days  or  once  a 
month.  In  some  cases  consciousness  returns  in  a  few 
minutes,  whilst  in  others  the  patient  remains  in  a 
stupid  condition  for  hours  and  may  remain  so  for 
some  days.  It  is  stated  that  the  longer  the  prodromal 
stage  the  more  severe  will  be  the  seizure,  and  vice  versa. 

In  "  petit  mal "  the  paroxysm  may  begin  either  with  a 
twitching  of  one  side  of  the  face,  a  turning  of  the  tongue 
to  one  side,  extreme  giddiness,  or  cramps  in  the  limbs  ; 
loss  of  consciousness  and  a  slight  convulsion  follow.  In  a 
great  number  of  cases  there  is  no  convulsion,  but  the 
patient,  whilst  talking  or  performing  some  act,  becomes 
unconscious,  and  is  seen  to  stare  vacantly ;  if  sitting  he 
becomes  motionless,  and  if  conversing  suddenly  silent,  and 
fails  to  comprehend  questions  addressed  to  him. 

From  simple  epilepsy  the  specific  form  may  be  dis- 
tinguished by  the  history  of  the  case  ;  simple  epilepsy  is 


PARASYPHILIS  OR   QUATERNARY  SYPHILIS     109 

generally  developed  before  puberty,  whereas  the  specific 
form  begins  usually  between  twenty  and  thirty.  The  simple 
seizures  are  uninfluenced  by  mercury  or  the  arylarsonates, 
whereas  the  specific  forms  respond  to  both. 

Treatment   of  syphilitic   epilepsy   consists  of  mercury, 
arylarsonates,  iodides,  and  of  course  bromides. 


CHAPTER   X 

THE   GENERAL  TREATMENT   OF   SYPHILIS 

UNTIL  quite  recently  mercury  was  recognised  as  the  only 
specific  for  syphilis,  but  now  there  is  reason  to  believe 
that  in  the  arylarsonates  we  are  in  possession  of  a  second  ; 
indeed,  this  is  certain  as  far  as  concerns  their  power  of 
preventing  the  occurrence  of  syphilitic  symptoms  and  of 
causing  their  disappearance  ;  but  whether  they  are  capable 
of  effecting  an  eventual  permanent  cure  remains  an  open 
question,  which  can  only  be  determined  by  time  and 
further  experience.  At  one  time  the  iodides  were  sup- 
posed to  be  specific  in  their  action,  but  for  many  years 
past  they  have  been  looked  on  as  adjuncts  only  to 
mercury,  and  as  possessing  no  specific  power. 

Abortive  Treatment. — Many  attempts  have  been  made 
by  cauterisation  and  excision  of  the  primary  lesion  to 
prevent  constitutional  infection,  but  have  invariably  failed. 
Metchnikoff  has  endeavoured  to  destroy  in  situ  the  Spiro- 
chceta  pallida  by  the  application  of  a  30  per  cent,  calomel 
ointment,  with  a  certain  amount  of  success  ;  his  experiments 
on  monkeys  proved  successful  in  preventing  the  develop- 
ment of  the  disease  when  applied  to  the  point  of  inoculation 
within  an  hour  or  two  of  infection,  as  also  in  the  case  of 


THE   GENERAL   TREATMENT  OF  SYPHILIS       in 

the  medical  student  already  quoted,  in  whose  case  in- 
unction at  the  point  of  inoculation  prevented  further 
developments.  Neisser  says :  "  There  is  no  doubt  that 
by  the  application  of  strong  mercurial  ointments  very 
many  syphilitic  infections  could  be  avoided,  and  I  hold  it 
to  be  the  duty  of  every  doctor  to  publish  this  fact  when- 
ever he  can,  and  to  advise  this  individual  prophylaxis." 
This  question  may,  at  present,  be  considered  to  be  sub 
judice. 

Specific  Medication. — Many  drugs  have  been  used  in 
the  treatment  of  syphilis ;  among  others  sarsaparilla, 
guaiacum,  sassafras,  sulphur,  arsenic,  gold,  silver,  platinum, 
and  many  vegetable  preparations  ;  iodide  of  potassium,  and 
last,  but  needless  to  say  not  least,  mercury,  and,  as  already 
mentioned,  the  arylarsonates.  But  most  of  these  have 
long  ago  ceased  to  be  employed  in  the  treatment  of 
syphilis.  Sarsaparilla  proves  of  benefit  in  syphilis  under 
certain  circumstances  ;  but  this  is  probably  due  more  to 
its  tonic  and  depurative  effects  than  to  any  specific  action. 
At  one  time  iodide  of  potassium  was  believed  to  be  a  true 
specific  in  syphilis,  but  it  has  long  ago  been  relegated  to 
a  position  as  a  mere  adjunct  to  the  real  specifics — mercury, 
and  now  the  arylarsonates. 

Mercury. — With  the  possible  exception  of  quinine  in 
malaria,  no  other  drug  is  more  worthy  of  the  name 
"  specific  "  than  is  mercury  in  its  action  upon  syphilis  ; 
nevertheless  it  has  had  its  ups  and  downs,  at  one  time 
it  was  considered  to  be  indispensable  for  the  cure  of  the 
disease,  at  others  it  was  looked  on  as  useless,  and  at  one 
period  it  fell  into  utter  disrepute,  as  not  only  being  useless, 


112    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

but  was  accused  of  being  the  cause  of  half  the  misfortunes 
which  had  hitherto  been  attributed  to  syphilis  itself.  No 
doubt  this  was  partially  true,  owing  to  the  barbarous  and 
unscientific  way  mercury  was  administered.  It  was  during 
the  Peninsular  War  that  this  state  of  things  was  first  brought 
forward,  principally  by  Guthrie  ;  the  position  of  mercury 
was  seriously  threatened,  until  it  was  in  danger  of  being 
removed  altogether  from  the  category  of  syphilitic  remedies. 
The  situation  was  saved  by  William  Ferguson,  who  calmly 
and  lucidly  explained  the  true  position  of  affairs,  and 
advocated  the  employment  of  mercury  in  doses  sufficient 
to  bring  about  its  physiological  effects  short  of  the 
salivation  which  had  previously  been  the  custom. 

It  was  many  years  before  mercury  recovered  its  good 
name,  or  rather  lost  its  bad  reputation  ;  and  even  to  this 
day  it  is  a  drug  which  is  hated  and  detested  by  the 
general  public  as  being  the  cause  of  unheard-of  woes  ; 
and  many  a  case  of  syphilis  has  been  allowed  to  have 
its  full  swing  owing  to  the  refusal  of  the  patient  to  undergo 
mercurial  treatment  through  dread  of  its  effects. 

There  is  little  cause  for  fear  of  mercury  if  administered 
properly  and  in  therapeutic  doses  ;  at  the  same  time  there 
are  undoubtedly  certain  dangers  attaching  to  it — (i)  saliva- 
tion, (2)  gastro-intestinal  symptoms,  (3)  cutaneous  erup- 
tions, (4)  disorders  of  nutrition. 

Salivation. — The  stomatitis  seen  to-day  is  generally  of 
a  mild  type,  and  does  not  damage  the  teeth  or  jaws ; 
but  sometimes  even  now  severe  cases  occur,  varying  in 
degree  from  slight  swelling  of  the  gums  to  intense  inflam- 
mation of  the  whole   buccal    mucous   membrane,  accom- 


THE   GENERAL   TREATMENT  OF  SYPHILIS       113 

panied  by  deep  ulcerations,  local  gangrene,  necrosis  of 
the  jaw,  and  loss  of  teeth.  Salivation  of  this  sort  is 
nearly  always  the  result  of  faulty  methods  of  admini- 
stration, or  of  neglect  of  buccal  hygiene.  A  few  cases, 
however,  are  due  to  some  peculiar  intolerance  to  mercury 
on  the  part  of  the  patient. 

Before  beginning  a  course  of  mercury  all  old  stumps 
should  be  extracted,  and  teeth  freed  from  tartar  and 
regulated  as  far  as  possible.  Clear  and  concise  rules 
should  be  given  to  the  patient  about  the  care  of  his 
teeth  and  gums  whilst  he  is  undergoing  treatment  by 
mercury ;  he  should  be  warned  as  to  the  necessity  of 
washing  his  teeth  after  each  meal,  and  advised  to  use 
some  mouth  wash  frequently  during  the  day,  such  as 
chlorate  of  potash  (5  grs.  to  the  ounce),  or  better — 

R  1.  2. 

Plumbi  acetatis    .     3"  j.  Aluminis  sulph.    .     3"  j. 

Aquam,  ad  .         .     3"  v.  Aquam,  ad  .         .     5 v- 

1  and  2  to  be  mixed  and  filtered. 

Or  the  gums  may  be  painted  two  or  three  times  a  day 
with  a  solution  of  peroxide  of  hydrogen,  or  perhydrol, 
which  is  a  50  per  cent,  solution  of  peroxide  of  hydrogen, 
but  which  is  quite  non-irritating  and  most  beneficial  in 
keeping  the  gums  healthy.  Another  excellent  application 
in  cases  showing  any  tendency  to  pyorrhoea  is  powdered 
sulphate  of  copper  applied  to  the  roots  of  the  teeth  by 
means  of  a  pointed  stick  or  match.  Should  stomatitis  of 
any  severity  occur,  all  mercury  must  be  stopped,  saline 
aperients  freely  administered,  and  a  mixture  of  chlorate 
of  potash  (gr.  xv)  should  be  given   three   times   a   day. 


114    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Sweating  should  be  induced  by  means  of  hot  air  or 
Turkish  baths,  and  the  patient  kept  as  much  as  possible 
in  the  open  air.  The  greatest  attention  must  be  paid 
to  the  teeth  and  gums  in  such  cases,  which  latter  ought 
to  be  painted  frequently  during  the  day  with  either  per- 
hydrol,  solutions  of  chromic  acid,  or  sulphate  of  copper. 
Gastro-intestinal  complications  consist  of  pains  in 
the  stomach,  colic,  and  diarrhoea  ;  later  on  of  dyspepsia 
and  loss  of  appetite.  Diarrhoea,  although  at  first  slight, 
may  at  times  become  very  severe  and  assume  dysenteric 
characters,  with  the  passage  of  blood,  slime,  and  mucus. 
A  fatal  result  may  follow.  The  gastro-intestinal  dis- 
turbance is  followed  by  anaemia,  want  of  appetite,  and 
emaciation. 

METHODS   OF   ADMINISTERING   MERCURY 

Mercury  is  introduced  into  the  system  by  different 
methods,  the  principal  being — (i)  by  the  internal  or 
ingestion  method  ;  (2)  by  inunction  ;  (3)  by  intramuscular 
injections.  It  is  also  administered  by  intravenous  injec- 
tion, by  fumigation,  by  suppositories,  and  by  inhalation 
with  the  aid  of  Wailender's  bag. 

The  points  to  be  considered  in  a  choice  of  method  are  : 

1.  Convenience  of  the  patient. — Which  can  be  employed 
with  the  greatest  convenience  to  the  patient  ? 

2.  Suitability  to  prolonged  use. — Which  of  them  will 
best  enable  us  to  carry  out  the  treatment  over  the 
lengthened  period  we  know  to  be  necessary  to  effect 
an  eventual  cure,  or  with  a  view  to  preventing  future 
ravages  of  the  disease  ? 


THE   GENERAL   TREATMENT  OF  SYPHILIS        115 

3.  Regularity  of  treatment. — Which  of  them  will  best 
ensure  regularity  of  treatment  ? 

4.  Rapidity  of  action  in  urgent  cases. — Which  to  adopt 
in  severe  cases  of  syphilis  with  urgent  symptoms? 

The  Ingestion  Method.— By  the  ingestion  or  internal 
method  is  meant  the  giving  of  mercury  by  the  mouth, 
depending  on  the  stomach  and  intestines  for  its  absorption. 
It  is  the  plan  which  even  to  this  day  is  usually  employed 
in  British  practice  generally. 

Before  considering  the  technique  of  this  method  it  will 
be  well  to  see  what  are  its  advantages  and  disadvantages. 
First  it  is  claimed  that  it  is  the  easiest  and  most  convenient 
method  for  the  patient  to  carry  out.  Second,  that  it  is 
free  from  certain  dangers  and  inconveniences  which  are 
inherent  in  other  methods — i.e.  that  it  is  much  less  likely 
to  be  followed  by  stomatitis,  and  that  the  latter  when  it 
does  occur  is  far  less  severe  than  when  produced  by  any 
of  the  other  methods. 

With  regard  to  its  being  the  easiest  and  most  con- 
venient method  for  the  patient  to  carry  out,  in  the  writer's 
opinion,  this  will  not  hold  ground  at  least  with  the  plan 
of  introducing  mercury  by  intramuscular  injections  :  surely 
an  injection  once  a  week  is  far  preferable  to  being  obliged 
to  take  medicine  three,  four,  or  perhaps  five  times  a  day 
for  weeks  and  months  at  a  time.  As  to  stomatitis,  this 
may  be  less  severe  than  when  it  is  produced  by  inunction 
or  intramuscular  injection,  but  it  is  none  the  less  frequent 
— certainly  not  when  compared  with  the  intramuscular 
method. 

The  disadvantages  of  the  ingestion  method  are  :  Firstly, 


n6   SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

given  in  this  manner  there  is  no  guarantee  as  to  how- 
much,  if  any,  of  the  mercury  is  absorbed.  Many  cases 
are  on  record  in  which  it  has  been  shown  that  mercurial 
pills  were  passed  through  the  intestinal  tract  unchanged 
in  any  way.  One  case  is  within  the  knowledge  of  the 
author  of  a  patient  taking  grs.  x  of  blue  pill  daily 
for  a  period  of  three  months  without  any  physiological 
effects  having  been  produced.  It  was  discovered  later 
that  the  pills  were  regularly  voided  in  the  same  condition 
in  which  they  had  been  taken. 

Secondly,  sooner  or  later,  in  the  majority  of  cases, 
mercury  introduced  by  the  internal  method  is  more  or 
less  certain  to  produce  gastric  or  gastro-intestinal  irritation 
with  all  the  concomitant  effects — i.e.  diarrhoea,  debility,  and 
anaemia.  The  mercury  has  to  be  withheld,  and  then  the 
syphilitic  virus  gets  the  chance  of  reasserting  itself.  The 
third  objection  to  the  internal  method  is  uncertainty  as 
to  its  being  carried  out  with  anything  like  regularity,  and 
this  to  the  author's  mind  is  the  chief  objection  to  the 
method. 

The  uncertainty  as  to  regular  administration  may  be 
due  either  to  the  patient's  absentmindedness  in  forgetting 
to  take  his  medicine,  or,  on  the  other  hand,  to  his  de- 
liberately giving  it  up  on  the  disappearance  of  active 
symptoms.  To  put  the  matter  plainly,  it  is  easy  for  the 
medical  man  to  sit  down  and  write  a  prescription  for 
mixtures,  pills,  or  powders,  with  instructions  to  his  patient 
to  take  one  of  them  three  or  four  times  a  day  for  months 
at  a  time ;  but  it  is  quite  another  thing  to  expect  these 
instructions  to  be  carried  out  with  anything  like  regularity. 


THE   GENERAL    TREATMENT  OF  SYPHILIS        117 

The  conscientious  patient,  with  the  best  intentions  possible 
of  adhering  strictly  to  his  instructions,  places  his  medicine 
each  morning  in  his  pocket  with  the  intention  of  taking 
it  during  the  day ;  how  often,  when  the  end  of  the  week 
comes,  can  he  look  back  and  say  he  has  taken  it  regularly 
during  every  day  of  the  week  ?  Yet  to  be  of  any  use 
we  know  that  regularity  in  taking  the  mercury  is  an 
absolute  necessity.  On  the  other  hand,  the  ordinary 
patient  approaches  the  matter  in  a  different  spirit,  and 
deliberately  gives  up  his  mercury  as  soon  as  the  activity 
of  the  disease  has  ceased  for  any  time. 

Technique  of  the  Ingestion  Method. — In  considering 
the  technique  of  the  internal  method  it  is  needless  to  say 
that  the  preparations  of  mercury  used  are  innumerable. 
Here  it  will  suffice  to  mention  the  chief  of  these  mercurial 
compounds  : 

1.  Metallic  mercury,  which  is  administered  in  different 
ways,  and  enters  into  some  of  the  most  famous  prepara- 
tions— i.e.  "  blue  pill "  : 

R  Purified  mercury  ....     5    grins. 

Powdered  liquorice       .         .         .     i\     „ 
Confection  of  roses       .         .         .     "j\     „ 

Divide  into  100  pills,  each  containing  5  centigrams 
of  mercury. 

"  Sedillot's  pills  "  : 

&  Mercurial  ointment       .         .         .30  grms. 

Powdered  soap      .         .         .         .     20     „ 
Powdered  liquorice        .         .         .     10      „ 

Misce  et  div.  in  pil.  xx. 


n8    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

English  "grey  powder": 

R  Mercury I  part. 

Powdered  chalk    ...         .3  parts. 

This  last  is  of  all  preparations  of  mercury  the  favourite 
one  in  England  in  the  treatment  of  syphilis. 

2.  Calomel  is  not  used  very  extensively  internally,  owing 
to  its  liability  to  bring  on  diarrhoea  and  stomatitis  ;  it  is 
chiefly  given  in  the  form  of  "Plummer's  pills." 

3.  Biniodide  of  mercury  is  a  very  toxic  agent,  but  is 
sometimes  employed  in  conjunction  with  iodide  of 
potassium. 

4.  Tannate  of  mercury  "is  not  a  definite  compound," 
and  in  spite  of  the  advantages  claimed  for  it  is  not  to 
be  recommended. 

5.  Salicylate  of  mercury. 

6.  Proto-iodide  and  sublimate  have  proved  the  best  and 
most  reliable  of  all  mercurial  remedies  given  internally. 
Perchloride  of  mercury  (corrosive  sublimate)  has  been 
and  is  most  popular  in  England.  Among  other  celebrated 
preparations  of  which  it  is  the  basis  Dupuytren's  pills  are 
perhaps  the  most  famous.     The  formula  is  as  follows : 

R         Perchloride  of  mercury      .         .         .     eg.  j    (gr.  \) 

Ext.  of  opium eg.  ij    (gr.  I) 

Ext.  of  guaiacum       .         .         .         .     eg.  iv  (gr.  §) 

It  also  enters  into  a  very  celebrated  French  preparation 
which  is  still  extensively  used  in  that  country — viz.  Van 
Swieten's  liquor. 

R         Bichloride  of  mercury  1  grm. 

Alcohol  (90  per  cent.)      .         .        .         .100  grms. 
Distilled  water 9°°    » 


THE   GENERAL   TREATMENT  OF  SYPHILIS 


119 


The  strength  is  1  in  1,000,  so  that  each  tablespoon 
contains  exactly  \\  eg.  of  corrosive  sublimate.  This 
preparation  ought  to  be  taken  well  diluted,  and  is  best 
given  in  milk. 

Van  Swieten's  liquor  has  not  the  same  formula  in  all 
countries.  Thus  the  French  liquor  is  stronger  than  that 
of  the  Spanish  pharmacopoeia,  and  weaker  than  the 
English. 

Sublimate  also  forms  the  basis  of  various  other  prepara- 
tions :  e.g.  Hoffman's  pills,  which  are  composed  of  subli- 
mate, distilled  water,  and  breadcrumbs  ;  Chomel's  pills, 
consisting  of  equal  parts  of  sublimate  and  extract  of 
opium  (|  eg.  in  each  pill) ;  and  Baron  Larrey's  syrup, 
composed  as  follows  : — 

B  Sarsaparilla 

Guaiacum 
Sassafras 
Senna 

Chiretta  root    . 
Elder 

Bichloride  of  mercury 
Ext.  opii  liq.    . 
Hydrochlorate  of  ammonia 


•  500  grm. 


^aa  eg.  xxv. 


Fournier  suggests  the  following  modification  of  Dupuy- 
tren's  pills  : — 

B  Bichloride  of  mercury 

Ext.  of  opium     . 


'  jaa  eg.  j  (gr,  J) 


for    one    pill,    as   containing   less    opium.      These    pills 
are  best  taken  during  or  before  meals. 

Proto-iodide  of  mercury  is   a   salt   of  greenish   yellow 
colour,  changing  with  the  light,  almost  insoluble  in  water, 


l2o    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

and  insoluble  in  alcohol.  It  was  introduced  into  thera- 
peutics by  Biett,  and  popularised  by  Ricord,  whose 
celebrated  pills  have  the  following  formula  : — 


Proto-iodide  of  mercury 

.     grm.  iij 

Ext.  of  thebain     . 

5>     J 

Theriaca      .... 

„     iij 

Confection  of  roses 

„     VJ 

Misce  et  div.  in  pil.  Ix. 

Each  pill  contains  -^  grm.  of  the  proto-iodide. 

There  can  be  no  doubt  that  for  ingestion  purposes 
corrosive  sublimate  and  the  proto-iodide  are  the  best 
mercurial  preparations  to  use.  In  France  the  proto-iodide 
is  the  most  popular,  whereas  the  perchloride  is  given  the 
preference  in  England. 

Both  sublimate  and  the  proto-iodide  are  excellent  in 
their  way,  but  one  or  the  other  may  be  more  suitable 
under  certain  conditions :  thus,  proto-iodide  is  more 
likely  to  be  followed  by  salivation  than  sublimate,  which 
is  probably  the  result  of  the  proportionally  larger  dose 
of  the  former  which  is  necessary  in  order  to  bring  about 
physiological  effects  than  is  required  in  the  case  of 
sublimate. 

Thus  proto-iodide  must  be  considered  a  salivating 
remedy,  with  a  view  to  guarding  against  the  occurrence 
of  affections  of  the  mouth  which  may  result  from  it. 
No  doubt  it  is  less  salivating  than  calomel,  and  also  than 
mercurial  inunctions ;  but  it  is  salivating  to  a  certain 
extent,  which  is  the  principal  objection  to  its  use,  and 
it  will  be  of  the  greatest  importance  to  arrive  at  a  more 
or    less   definite   conclusion   as    to   what    is    the    buccal 


THE   GENERAL   TREATMENT  OF  SYPHILIS       121 

tolerance  dose  of  this  remedy.  With  regard  to  the  degree 
of  buccal  tolerance,  excluding  individuals  with  idiosyn- 
crasies towards  intolerance,  there  is  a  marked  difference 
in  the  two  sexes  :  a  woman's  mouth  tolerates  the  proto- 
iodide  much  less  than  a  man's. 

For  men  we  may  say  that  a  daily  dose  of  f  gr.  is 
absolutely  inoffensive,  and  that  in  nine  cases  out  of  ten 
a  dose  of  if  gr.  is  tolerated  without  evil  effect,  provided 
that  the  mouth  is  in  good  order  and  is  kept  so  during 
treatment. 

It  may  be  considered  that  a  daily  dose  of  if  gr.  of 
proto-iodide  is  the  average  dose  of  buccal  toleration  in 
men.  Of  course,  much  larger  doses,  up  to  3  grs.,  are 
sometimes  well  tolerated. 

As  regards  the  other  sex,  there  are  few  women  in  whom 
the  mouth  tolerates  without  irritation  a  dose  of  if  gr., 
with  which  dose  stomatitis  is  nearly  always  imminent, 
and  seldom  fails  to  occur  if  treatment  is  continued.  The 
average  dose  of  buccal  toleration  can  be  put  down  as 
1  gr.  of  the  proto-iodide. 

Action  on  the  Digestive  Organs. — In  this  respect 
there  are  notable  differences  between  the  two  preparations 
under  consideration. 

In  therapeutic  doses  sublimate  affects  the  stomach 
rather  than  the  intestine,  rarely  producing  diarrhoea, 
whilst,  even  in  moderate  doses,  it  often  disturbs  the 
stomach,  causing  cramps,  pains,  and  strange  sensations, 
often  of  such  severity  that  treatment  has  to  be  suspended 
for  a  time  at  least.  These  pains  are  known  as  "  sublimate 
gastralgia."     Women   suffer   in   this    respect   much    more 


122    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

than  men — so  much  so  that  it  is  questionable  if  some 
other  preparation  of  mercury  should  not  always  be  pre- 
ferred to  the  sublimate  in  the  case  of  women. 

Sublimate  is  tolerated  by  the  stomach  if  care  be  taken 
not  to  prescribe  too  large  doses  of  it,  and  not  to  continue 
it  for  too  long  a  period,  for  even  when  well  tolerated 
by  the  stomach,  this  is  only  for  a  time,  after  which  it 
causes  harm.  Clinical  experience  taught  me  that  from 
three  to  four  weeks  was  the  limit  of  this  period,  hence 
I  made  a  rule  never  to  prescribe  sublimate  for  longer 
than  a  month  at  a  time. 

The  proto-iodide  seldom  or  never  affects  the  stomach 
in  any  way,  but  in  nearly  every  case  proto-iodide  is 
followed  by  slight  attacks  of  colic  and  diarrhoea  when 
first  given  :  this  is  called  "  premonitory  diarrhoea " ;  it 
soon  passes  off,  and  no  further  trouble  may  be  caused 
during  a  long  course  of  the  salt.  On  the  other  hand, 
some  patients  are  troubled  with  sudden  attacks  of  diarrhoea 
varying  in  intensity  from  those  lasting  a  few  hours  to 
those  resembling  dysentery,  and  threatening  to  become 
permanent.  If  we  desire  to  produce  therapeutic  effects 
of  any  intensity  the  proto-iodide  is  far  preferable  to 
sublimate,  because  to  bring  about  the  same  results  with 
the  latter  it  would  be  necessary  to  raise  its  dose  to  a 
dangerous  degree. 

Sublimate  hardly  ever  affects  the  intestine  or  brings  on 
diarrhoea. 

From  what  has  been  seen  as  regards  these  two  salts,  it 
is  hard  to  give  preference  to  one  over  the  other.  They 
are  both  excellent  remedies,  each  having  its  advantages 


THE   GENERAL   TREATMENT  OF  SYPHILIS        123 

and  disadvantages.  All  that  can  be  affirmed  with  regard 
to  the  choice  of  either  of  them  is  that,  as  a  rule,  the  proto- 
iodide  ought  to  be  given  in  the  early  secondary,  and 
sublimate  kept  for  the  later  secondary  and  tertiary  stages. 
Sublimate  administered  in  the  first  stage  of  the  disease 
only  exercises  on  secondary  lesions  an  incomplete  action — 
that  is,  it  only  brings  them  to  an  end  slowly,  and  often 
allows  them  to  be  reproduced.  An  undoubted  advantage 
that  proto-iodide  has  over  sublimate  is  that  it  can  be 
continued  over  a  much  longer  period  without  causing  any 
trouble.  On  the  other  hand,  sublimate  is  preferable  to 
proto-iodide  in  the  later  stages  owing  to  its  undoubted 
greater  influence  over  the  late  lesions,  also  owing  to  its 
combining  better  with  iodide  of  potassium,  which  is  of 
importance. 

The  pros  and  cons  as  regards  the  employment  of  these 
two  salts  may  be  summarised  as  follows  : 

1.  With  sublimate  there  is  little  salivation,  but  gastric 
intolerance  is  very  frequent. 

2.  Gastric  disturbances  are  infrequent  with  proto-iodide, 
but  stomatitis  and  intestinal  troubles  are  often  caused 
by  it. 

It  is  needless  to  observe  that  the  choice  of  either  of 
these  salts  will  depend  a  great  deal  on  the  nature  and 
condition  of  the  case.  Thus  for  patients  with  bad  teeth 
sublimate  should  be  the  chosen  salt ;  whereas  in  those 
inclined  to  suffer  from  dyspepsia  and  gastric  troubles 
proto-iodide  should  be  selected. 

As  to  the  best  forms  to  order :  sublimate  is  usually 
prescribed  in  solutions  or  in  pills.     A  favourite  solution, 


124    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

especially  in  France,  has  been  and  is  Van  Swieten's  liquor, 
whilst  in  pill  form  Dupuytren's  pills  (p.  118)  are  much  in 
favour.  As  an  improvement  on  that  formula  Fournier 
suggests  the  following : 

R  Bichloride  of  mercury       .         ."|_ 

Extract  of  opium      .        .        f1*^* 

As  a  mixture,  sublimate  is  generally  ordered  either  in 
water  or  some  tonic  infusion.  A  stock  mixture,  which  is 
a  favourite  one  in  English  practice,  is  one  containing  liq. 
hydrarg.  perchl.  and  iodide  of  potassium,  and  this  is  given 
for  unlimited  periods ;  but  the  less  said  about  such  a 
practice  the  better,  except  to  condemn  it  freely. 

Owing  to  its  insolubility  the  proto-iodide  can  only  be 
ordered  in  the  form  of  pills,  those  of  Ricord  being  still 
ever  popular  ;  but  here  again  as  an  improvement  Fournier 
suggests  the  following : 

R:  Proto-iodide  of  mercury       .         .     5  eg.  (|  gr.) 

Extract  of  opium  .         .         •!»(£,») 

as  containing  less  opium  than  the  original,  and  as  affording 
greater  scope  for  increasing  or  lessening  the  dose.  A  draw- 
back to  both  Dupuytren's  and  Ricord's  pills  is  that  they 
contain  opium,  which  is  to  my  mind  a  mistake.  Since 
opium  has  no  curative  action,  what  advantage  is  there 
in  systematically  combining  it  with  mercury,  and  very 
often  for  the  whole  duration  of  the  treatment  ?  Personally 
I  think  it  should  only  be  added  when  required. 

Dosage. — With  regard  to  dosage  it  may  be  taken  for 
granted  that  the  dose  of  mercury  ordered  is,  in  nine  cases 


THE   GENERAL   TREATMENT  OF  SYPHILIS       125 

out  of  ten,  lower  than  that  consistent  with  the  physio- 
logical effects  which  are  necessary.  This  is  generally  the 
result  of  timidity — in  other  words,  having  to  keep  on  the 
right  side,  which  leads  to  insufficient  treatment.  It  be- 
comes all  the  more  needful,  then,  for  each  individual  case 
of  syphilis  to  be  studied  separately,  with  a  view,  if  possible* 
of  arriving  at  some  idea  as  to  what  dose  can  be  ordered 
with  safety — a  dose  which  at  the  same  time  will  be  large 
enough  to  exert  its  full  therapeutic  effects.  It  may  truly 
be  said  that  no  two  cases  of  syphilis  stand  mercury  alike, 
more  especially  when  given  by  the  internal  method.  It 
is  almost  impossible  to  lay  down  a  rule  as  to  what  is  the 
dose  of  either  the  bichloride  or  proto-iodide  ;  it  can  only 
be  surmised.  As  regards  sublimate  it  can  be  considered 
as  gr.  \  daily  for  a  man  and  gr.  \  for  a  woman  ;  the  dose 
of  proto-iodide,  as  already  stated,  is  gr.  i|  daily  for  a  man 
and  gr.  1  for  a  woman.  These  are  the  average  doses,  but 
the  average  dose  is  not  always  the  most  efficacious :  not 
all  manifestations  of  syphilis  are  equally  influenced  by 
the  same  dose  of  mercury.  There  are  some  which  dis- 
appear with  small  doses,  such  as  roseola  or  any  of  the 
generalised  syphilides,  while  the  same  doses  would  have  no 
effect  whatever,  on,  for  instance,  cerebral  syphilis.  Again, 
it  must  ever  be  remembered  that  subjects  respond  differ- 
ently to  mercury,  some  to  doses  of  the  drug  which  would 
be  too  small  to  have  the  slightest  effect  on  others,  so  that 
in  giving  mercury  it  behoves  us  to  find  out  what  is  the 
"  dose  for  the  patient." 

Remarks  on  the   Internal  Method. — Personally,   my 
experience  of  treating  syphilis  by  the  ingestion  plan  ex- 


126    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

tended  over  a  good  many  years,  during  which  time  I  made 
use  of  most  of  the  preparations  above  described.  I  found 
that,  in  the  majority  of  cases  thus  treated,  after  mercury 
had  been  administered  for  a  period  of,  say,  a  month  or 
six  weeks,  it  began  to  disagree  in  one  way  or  the  other. 
In  some  cases  stomatitis  appeared,  the  digestive  system 
became  impaired,  and  as  a  consequence  the  general 
condition  of  health  began  to  suffer,  a  condition  of 
malnutrition  resulted,  and  the  disease  either  remained 
in  statu  quo,  or  else  further  and  worse  outbreaks  of  it 
occurred  ;  and  in  either  case  the  drug  had  to  be  dis- 
continued for  a  time  at  least.  This  same  series  of  events 
went  on,  the  patient  gradually  drifting  into  a  chronic 
syphilitic  state  ;  he  never  got  a  chance  of  anything  like 
a  continued  treatment,  and  consequently  never  got  cured. 
Another  lesson  I  learnt — that  with  this  plan  of  treatment 
there  was  no  certainty  of  the  patient  getting  his  medicine 
with  any  regularity ;  on  the  contrary,  I  had  reason  to 
suspect,  and  afterwards  found'  out,  that  in  the  majority 
of  instances  this  was  the  case,  and  in  a  great  many  the 
medicine  was  dropped  altogether.  The  fact  is,  that  as 
the  taking  of  the  medicine  depends  absolutely  on  the 
patient  himself,  he  at  times  inadvertently  forgot  to  take 
it  ;  and  if  by  chance  he  happened  to  be  careless,  he 
dropped  it  altogether  when  no  urgent  symptoms  were 
present.  This  objection  seemed  to  me  to  be  so  serious 
and  insurmountable,  as  to  be  quite  sufficient  to  put  the 
ingestion  plan  of  giving  mercury  out  of  court. 

A  third  objection   is  that  years  ago  clinical  observation 
led  me  to  suspect  that  in  a  great  many  cases  treated  by 


THE   GENERAL   TREATMENT  OF  SYPHILIS       127 

this  method,  after  the  mercury  had  been  taken  for  any 
length  of  time,  the  organism  became  as  it  were  inured 
to  it,  and  the  drug  apparently  lost  all  its  physiological 
effects ;  while  in  other  cases  it  undoubtedly  passed 
through  the  system  unabsorbed. 


CHAPTER   XI 

TREATMENT   OF   SYPHILIS  {continued) 
INUNCTION 

The  External  or  Inunction  Method. — This  is  the 
oldest  known  method  of  administering  mercury.  It  was 
employed  in  the  fifteenth  century  against  the  ravages  of 
what  was  called  "  mal  francais,"  or  the  "  new  disease,"  and 
is  mentioned  by  Fracastor  in  his  poem  on  syphilis. 
Popular  before  all  other  methods  of  giving  mercury,  the 
inunction  plan,  through  the  reckless  manner  in  which  it 
was  carried  out,  gradually  lost  caste,  and  eventually  died 
out.  The  reaction  against  it  reached  its  highest  point 
during  the  Peninsular  War.  Gaspard  Torella,  writing  in 
1497,  says,  "  Avoid,  like  the  plague,  these  murderous 
ointments  which  already  have  made  so  many  victims  ;  it  is 
they  that  killed  Cardinal  Segube,  whose  brother  also  owes 
his  death  to  these  ointments." 

The  old  plan  of  inunction  consisted  not  only  in  a  series 

of    rubbings   with    mercurial    ointment,    but    in    addition 

purgation,    bleeding,    overheating,    and     dieting     to     the 

point    of  inanition  ;    these   conditions   were    supposed   to 

be  absolutely  necessary,  as   also   was    the    production   of 

stomatitis. 

128 


TREATMENT  OF  SYPHILIS— INUNCTION  129 

Here  is  a  description  of  the  inunction  method  as  then 
carried  out,  in  the  words  of  Ulrich  van  Hutten  (1488 — 
1523):  "Some  used  these  anointings  once  a  day,  some 
twice,  others  three  times  and  four  times  ;  the  patient 
being  shut  up  in  a  stove  with  continual  and  fervent  heat 
some  twenty,  some  thirty  whole  days  ;  some  laying  in 
bed  within  the  stove  with  many  clothes,  being  compelled 
to  sweat.  Part  at  the  second  anointing  began  to  faint ; 
yet  was  the  ointment  of  such  strength  that  whatsoever  dis- 
temper was  in  the  upper  parts  it  drew  into  the  stomach 
and  thence  to  the  brain  ;  and  so  the  disease  was  voided 
both  by  the  nose  and  mouth,  and  put  the  patient  to  such 
great  pain  that  except  they  took  good  heed  their  teeth 
fell  out,  and  their  throats,  their  lungs,  with  the  roofs  of 
their  mouths  were  full  of  sores  ;  their  jaws  did  swell, 
their  teeth  became  loosened,  and  a  stinking  matter 
continually  was  voided  from  these  places.  What  part  so- 
ever it  touched  the  same  was  strait  corrupted  thereby., 
so  that  not  only  their  lips  but  the  inside  of  their 
cheeks  were  grievously  pained,  and  made  the  place  where 
they  were  stink  abominably  ;  which  sort  of  cure  was 
indeed  so  terrible  that  many  chose  rather  to  die  than  to 
be  eased  thus  of  their  sickness.  Howbeit  scarce  one 
sick  person  in  a  hundred  could  be  cured  in  this  way, 
but  quickly  after  relapsed,  so  that  the  cure  held  out 
but  for  a  few  days." 

And  in  a  later  period  Syme  says  as  regards  this  form 
of  administering  mercury,  "  And  the  solitude  of  the 
syphilitic  ward  was  only  broken  by  the  noise  caused 
when   the   last  tooth   of   one   of    the   patients    fell    upon 

9 


130    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

the  floor."  The  patients  undergoing  treatment  as  above 
described  soon  became  debilitated  and  emaciated  ;  some 
were  reduced  to  a  state  of  syncope,  which,  however,  was 
regarded  as  a  favourable  sign  ;  they  were  advised  "  not 
to  become  discouraged,  and  to  look  forward  to  an  early 
cure." 

Such  treatment  naturally  caused  severe  salivation,  but 
this  was  looked  upon  as  being  necessary,  and  the  more 
profuse  the  salivation  the  better  the  outlook  was ;  it  was 
believed  that  the  disease  was  evacuated  by  the  mouth. 

Fracastor  exhorted  his  patients  thus  :  "  A  truce  to  the 
disgust  which  this  medication  may  inspire  in  you,  for 
this  is  the  price  of  your  cure.  Therefore  spread  this 
ointment  on  your  body,  and  cover  the  whole  skin,  except 
the  head  and  the  region  of  the  heart,  with  it.  Bear  this 
ordeal  for  ten  days,  the  benefit  of  which  will  soon  be 
felt.  Soon,  in  fact,  an  infallible  omen  will  announce  the 
hour  of  your  deliverance.  You  will  soon  feel  the  ferments 
of  the  disease  dissolve  in  your  mouth  by  an  unclean 
slime,  and  you  will  see  the  virus  evacuated  at  your  feet 
in  the  saliva."  The  amount  of  salivation  thought  to  be 
necessary  was  one  which  produced  five  or  six  pounds  of 
saliva  in  twenty-four  days,  but  the  famous  Dutch  physician 
Boerhaave  considered  that  a  hundred  pounds  should  be 
produced  in  thirty  days. 

Is  it  surprising,  then,  that  under  the  above  circumstances 
the  inunction  method  became  unpopular  and  fell  into 
disrepute?  It  died  out  altogether,  to  rise  again  under 
happier  auspices,  and  to  become  re-established  in  popu- 
larity.    The  methods  of  inunction  to-day  are  very  different 


TREATMENT  OF  SYPHILIS— INUNCTION  131 

from  those  of  yore.  They  simply  consist  of  a  certain  amount 
of  rubbings  with  a  mercurial  ointment  of  a  known  strength, 
combined  with  mild  diaphoresis,  good  diet  and  hygiene, 
with  a  total  absence  of  the  purging,  bleeding,  and  profuse 
sweating  and  salivation  which  had  hitherto  been  con- 
sidered necessary.  However,  popular  as  the  inunction 
method  became  on  the  continent  of  Europe,  it  never 
appears  to  have  attained  the  same  repute  in  England  even 
down  to  the  present  day,  and  this  in  the  face  of  the  teachings 
of  some  of  her  most  famous  syphilogists,  notably  John 
Hunter,  who  says :  "  When  mercury  can  be  thrown  into 
the  constitution  by  the  external  method  it  is  preferable 
to  the  internal,  as  the  skin  is  not  nearly  so  essential  to 
life  as  the  stomach." 

The  main  reason  why  the  plan  never  became  popular 
in  England  was,  I  believe,  due  to  the  ignorance  that 
existed  as  regards  its  necessary  technique ;  and  it  has 
always  been  an  enigma  to  me  why  England  has  not 
taken  example  in  this  matter  from  Aachen  (Aix-la- 
Chapelle),  for  there  during  the  last  century  and  a  half 
the  inunction  method  has  flourished  in  the  most  successful 
way.  Every  nation  has  benefited  more  or  less  by  it — 
none  more  so  than  England,  for  from  this  country 
syphilitic  patients  have  gone  to  this  place  year  after 
year,  cases  in  which  home  treatment  had  signally  failed, 
to  return  after  a  sojourn  of  a  couple  of  months  much 
improved. 


132    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

MODERN   TECHNIQUE    OF   THE   EXTERNAL 
METHOD 

This  can  best  be  given  by  describing  the  manner  in 
which  it  is  carried  out  at  Aix-la-Chapelle,  for  there,  as 
already  said,  it  has  been  done  for  the  last  century  and  a 
half  in  such  a  thorough  way  as  to  make  the  place  famous 
throughout  the  world  as  a  resort  for  the  successful  treat- 
ment of  syphilis,  and  to  have  led  to  hundreds  of  patients 
flocking  there  to  receive  that  alleviation  from  their 
disease  which  they  had  before  failed  to  obtain  from 
perhaps  one  or  two  years  of  sporadic  courses  of  treat- 
ment by  the  internal  method.  The  routine  treatment 
at  Aix-la-Chapelle  (Aachen)  is  as  follows  : 

(i)  A  visit  to  a  physician,  who  examines,  weighs,  and 
records  case. 

(2)  The  patient  rises  early  each  morning,  goes  to  one 
of  the  mineral  springs,  where  he  partakes  of  one  or  two 
glasses  of  the  sulphur  water. 

(3)  Breakfast,  consisting  perhaps  of  one  egg,  bread, 
butter,  and  coffee. 

(4)  One  or  two  hours  later  the  patient  proceeds  to  one 
of  the  many  baths,  and  there  has  his  bath,  which  consists 
of  the  natural  sulphur  water  at  a  temperature  of  390  C. 
In  this  he  remains  from  twenty-five  to  thirty  minutes  ; 
when  he  leaves  it  he  is  well  dried. 

(5)  Half  an  hour  afterwards  a  professional  rubber  rubs 
into  the  patient's  skin  75  grains  of  a  mercurial  ointment 
about  the  same  strength  as  our  Ung.  hydrarg.  (B.P.).  Each 
rubbing  lasts  from  fifteen  to  twenty  minutes.     To  avoid 


TREATMENT  OF  SYPHILIS— INUNCTION 


133 


the  effects  of  the  friction  caused  by  these  rubbings,  such 
as  dermatitis,  etc.,  the  parts  so  rubbed  are  changed  daily  : 

1  st  day,  the  arms  ; 

2nd  day,  the  forearms  ; 

3rd  day,  the  chest ; 

4th  day,  the  back  ; 

5th  day,  the  thighs  ; 

6th  day,  the  legs  ; 

7th  day,  the  sides  of  the  chest  and  loins ; 
and   on    the   eighth   day  the  arms  again,  and  so  on,  in 
rotation. 

Composition  of  the  Aachen  Water.— The  water  from 
the  Aachen  springs  contains  from  22  to  28  grammes  of 
chloride  of  sodium,  4  to  5  grammes  of  sulphates,  and  8 
to  12  grammes  of  carbonates  in  10,000  c.cm.,  and  their 
range  of  temperature  for  therapeutical  purposes  is  from 
380  C.  to  720  C. 
Gaseous  Constituents. — Gases  absorbed  in  water  : 


Nitrogen 
Carbonic  acid 
Carburetted  hydrogen 
Sulphuretted  hydrogen 
Oxygen 


9"oo 
39'4 
0-37 

1  "23 


Nitrogen 

Carbonic  acid 

Carburetted  hydrogen 

Oxygen 

Sulphuretted  hydrogen 


66-98 

30-89 

1-82 

Q'3^ 

IOO'OO 


Total  volume  of  absorbed  carbonic  acid,  free  and  partly  combined 
carbonic  acid,  251-5. 


134   SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

The  advantages  claimed  for  these  waters  are  that,  since 
in  the  administration  of  mercury,  remedies  are  required 
which  will  influence  the  whole  organism  as  well  as  its 
individual  parts,  and  thereby  favour  the  general  nutrition, 
the  circulation,  and  the  glandular  activity,  the  water 
of  Aachen  fulfils  these  requirements  in  every  way.  In 
the  first  place,  the  drinking  of  800  to  1,000  grammes  of 
the  sulphur  water  daily  improves  the  appetite,  increases  the 
excretion  of  the  kidneys,  and  regulates  the  bowels.  The 
regular  action  of  the  bowels  is  maintained  in  almost  every 
case,  thus  inflammation  of  the  intestines  consequent  on 
the  use  of  mercury  is  avoided. 

The  warm  baths,  on  account  of  the  quantity  of  soda 
which  they  contain,  greatly  facilitate  the  proper  cleansing 
of  the  skin  from  excessive  or  diseased  deposits  from  the 
epidermis  and  glands.  By  its  warmth  the  water  makes 
the  skin  pliable,  opens  its  pores,  and  increases  its  normal 
action  by  stimulating  the  circulation.  As  a  result, 
absorption  and  chemical  transformation  of  the  mercury 
in  the  ointment  are  facilitated. 

Mode  of  Action  of  Inunction :  How  does  Mercury 
penetrate  the  System? — The  fact  of  absorption  of 
mercury  by  the  skin  is  proved  in  three  ways:  (1)  by  the 
appearance  of  mercury  in  the  urine  ;  (2)  by  the  occurrence 
of  the  physiological  effects  of  mercury,  especially  stoma- 
titis ;  (3)  by  the  production  of  therapeutic  effects,  which 
are  often  intense. 

There  are  four  theories  as  to  the  manner  in  which 
mercury  penetrates  the  organism  :  (1)  mechanical  pene- 
tration in  a  state  of  fine  division  ;   (2)  absorption  in  the 


TREATMENT  OF  SYPHILIS— INUNCTION  135 

form  of  vapour  ;  (3)  absorption  by  the  hair  follicles  and 
sweat  glands  ;  (4)  some  authorities  maintain  that  mercury- 
does  not  penetrate  the  skin  at  all,  but  is  inhaled  after 
volatilisation  on  the  skin. 

The  majority  of  observers  nowadays  agree  that  most 
of  the  metal  penetrates  through  the  skin,  only  a  small 
amount  entering  by  the  lungs.  The  idea  that  the 
curative  action  of  inunction  is  due  to  the  volatilisation  of 
the  mercury  and  its  absorption  by  the  lungs  is  based 
on  the  fact  that  mercury  is  much  more  volatile  than 
was  formerly  supposed.  However,  if  the  mercury  were 
absorbed  by  inhalation,  hospital  patients  who  are  not 
taking  mercury,  and  most  certainly  rubbers,  would  be 
mercurialised  ;  but  this  is  not  the  case.  It  may  be  taken 
for  granted  that  the  amount  of  mercury  which  is  absorbed 
by  inhalation  is  but  a  negligible  quantity. 

Mercurial  Ointments  for  Inunction.  —  In  Aachen, 
generally  speaking,  the  ointment  used  is  the  Ung.  hydrarg. 
(G.P.). 

Sometimes  mercurial  soaps  are  used,  but  these  have 
the  disadvantage  of  requiring  a  considerable  time  for 
absorption.  On  the  other  hand,  they  are  said  to  be 
cleaner  and  also  less  irritating. 

At  the  Military  Hospital,  Rochester  Row,  the  following 
is  the  ointment  used  : 


r> 


Ung.  hydrarg 50  grs. 

Lanolin  hydro.        .         .         .         .         .  25     „ 

Adipis  benzoin.       .         .         ....       25     „ 

Divide  into  two  parts,  and  wrap  in  waxed  paper. 


136    SYPHILIS:   ITS  DIAGNOSIS  AND   TREATMENT 

Dosage. — No  rules  can  be  laid  down  as  to  the  actual  dose 
of  ointment,  as  this  depends  on  various  factors,  chief  among 
them  being  the  degree  of  tolerance  of  the  patient.  The 
average  dose  for  an  adult  is  5J,  and  this  can  be  increased 
to  5  ij,  according  to  the  tolerance  of  the  patient.  A 
somewhat  smaller  dose  should  suffice  for  a  woman ;  in 
the  case  of  an  infant  15  to  30  grs.  may  be  considered 
a  safe  dose. 

The  best  time  for  inunction  is  the  morning,  as  the 
movements  caused  by  exercise  favour  absorption. 

Mode  of  Rubbing. — The  part  rubbed  on  one  day  is 
not  scrubbed  until  the  morning  prior  to  its  being  again 
utilised.  The  rubbing  should,  when  possible,  be  carried 
out  by  trained  rubbers  ;  the  rubbing  should  be  done 
slowly,  evenly,  and  with  a  good  deal  of  pressure.  The 
part,  after  being  rubbed,  if  properly  done,  ought  to  look 
as  if  blacklead  had  been  used — shiny,  but  not  greasy. 
Each  rubbing  should  last  from  fifteen  to  twenty  minutes. 

Effect  on  Rubbers. — It  would  be  expected  that  the 
rubbers  might  be  injuriously  affected  from  inhalation  or 
absorption  of  mercury,  yet  this  is  not  the  case  ;  the  writer 
has  never  seen  any  ill  results  to  rubbers,  although 
following  the  custom  at  Aachen,  where  no  artificial  pro- 
tection to  the  hands  is  used.  At  Wiesbaden  and  other 
places  glass  balls  and  slabs  are  used  in  rubbing,  but  the 
experience  at  Aix,  which  coincides  with  that  of  the 
author,  is  that  the  rubbing  can  be  done  much  more 
efficiently  with  the  bare  hand. 

Number  of  Rubbings. — A  course  of  rubbings  at  Aix 
lasts  generally  six  weeks,  during  which  period  some  forty 


TREATMENT  OF  SYPHILIS— INUNCTION  137 

rubbings  are  administered  ;  but  in  England  I  think  that 
thirty  ought  to  be  the  maximum  number,  the  greater 
number  being  permissible  in  the  former  case  owing 
to  the  tolerance  which  is  brought  about  by  the  use  of 
the  natural  water,  which  of  course  is  unobtainable  for 
bathing  purposes  away  from  Aix.  In  my  opinion  all 
rubbings  ought  to  cease  after  a  maximum  of  thirty, 
followed  by  a  rest  of  at  least  two  months  prior  to  a  fresh 
course  being  commenced. 

Necessary  Precautions. — During  a  course  of  in- 
unction, and  for  some  time  after,  the  greatest  attention 
should  be  given  to  the  hygiene  of  the  mouth  :  the  patient 
must  be  instructed  to  look  to  the  state  of  his  gums  and 
the  cleanliness  of  his  teeth,  and  the  latter  should  be  well 
brushed  after  each  meal  with  a  fairly  soft  tooth-brush  ;  as 
a  matter  of  routine  some  astringent  mouth-wash  should 
be  used  frequently  during  the  day  :  a  favourite  one  which 
is  used  at  Rochester  Row  is — 

Aluminis  sulph.      .     1  ].  Plumbi  acetas    .     %  j. 

Aqua      .         .         .     1  v.  Aqua  .         .     3  v. 

Mix  and  filter. 

Should  the  gums  show  any  tendency  to  soreness  they 
may  be  painted  two  or  three  times  a  day  with  perhydrol 
or  a  solution  of  peroxide  of  hydrogen. 

Diet. — The  diet  should  be  generous,  the  patient  being 
told  to  live  well  and  to  drink  freely  of  new  milk.  Spirits 
should  be  forbidden,  but  beer,  claret,  and  hock  allowed  in 
moderation. 


138    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Exercise. — Exercise  in  the  open  air  is  to  be  very  much 
encouraged  ;  patients  undergoing  inunction  should  live 
and  sleep  in  large,  well-ventilated  rooms. 

Advantages  of  Inunction. — The  advantages  claimed 
for  the  inunction  method  are : 

i.  Therapeutic  effects  are  far  more  marked  than  when 
the  drug  is  given  by  the  mouth.  Undoubtedly  in  many 
cases  inunction  brings  about  a  cure  in  which  other 
methods  failed ;  especially  is  it  useful  in  all  syphilitic 
sclerotic  affections,  such  as  the  primary  induration, 
sclerotic  glossitis,  and  tabes,  etc.,  in  which  cases,  although 
the  usual  dose  of  the  mercurial  ointment  may  have  to 
be  raised,  it  very  often  proves  most  beneficial. 

2.  It  does  not  affect  the  alimentary  system.  There  is  no 
doubt  that  mercury  when  administered  by  the  skin,  very 
rarely  affects  the  digestive  system,  at  any  rate  not  nearly 
so  frequently  as  when  introduced  by  the  ingestive  plan. 
Valuable  as  this  is  in  any  case,  it  is  much  more  so  in  the 
case  of  dyspeptic  subjects,  in  those  liable  to  diarrhoea,  in 
subjects  in  whom  it  is  important  to  support  the  general 
condition,  and  in  infants  and  young  children. 

3.  It  leaves  the  stomach  free  for  the  administration 
of  other  remedies.  This  is  certainly  a  great  boon,  for 
whilst  the  specific  treatment  is  going  on  other  remedies 
may  be  used,  such  as  iodide  of  potassium,  cod  liver  oil, 
tonics,  etc. 

Disadvantages  of  Inunction. — 1.  Treatment  by  the 
inunction  method  can  only  be  of  a  very  intermittent 
kind,  which  is  opposed  to  our  judgment  as  regards 
ultimate   cure   and    prevention.     What   is  meant  by  this 


TREATMENT  OF  SYPHILIS— INUNCTION         139 

is  that  the  courses  of  rubbings  cannot  be  continued  long 
enough,  nor  resorted  to  frequently  enough,  to  enable  us 
to  carry  out  the  chronic  intermittent  treatment. 

2.  It  is  very  frequently  followed  by  severe  stomatitis, 
and  often  by  diarrhoea  and  dermatitis.  Although  as  a 
rule  mercury  when  administered  by  the  skin  does  not 
affect  the  alimentary  canal,  still  at  times  it  does  so,  causing- 
pain,  colic,  and  diarrhoea.  Dermatitis  is  more  common, 
and  is  usually  limited  to  the  sites  of  the  inunction  :  it  is 
in  most  cases  the  result  of  local  irritation  on  a  delicate 
skin,  and  in  a  few  to  some  idiosyncrasy.  In  the  former 
it  generally  occurs  in  the  form  of  an  erythema,  either 
circumscribed  or  diffuse,  whilst  in  the  latter  it  may  appear 
as  an  eczema,  which  consists  in  a  deep  red  area  of 
erythema  covered  with  vesicles  full  of  clear  fluid  which 
later  on  becomes  turbid ;  this  is  accompanied  by  inflam- 
mation and  swelling  of  the  skin  with  heat  and  pruritus. 

Stomatitis  is  far  more  common  than  diarrhoea  or 
dermatitis  ;  and  it  is  certainly  one  of  the  chief  objections 
to  the  inunction  method  that  of  all  modes  of  introducing 
mercury  into  the  system  inunction  is  the  most  likely  to 
cause  stomatitis  :  some  of  the  worst  cases  of  this  which 
the  author  remembers  having  seen  occurred,  either  at 
Aachen  or  elsewhere,  in  patients  whilst  undergoing 
inunction.  Moreover,  the  form  of  stomatitis  resulting 
from  inunction  differs  considerably  from  that  produced  by 
ingestion  of  mercury  :  it  comes  on  more  suddenly,  without 
any  warning  ;  instead  of  beginning  at  some  particular  spot 
and  spreading  gradually,  it  is  general  and  extensive  from 
the   first  ;   it   is    more    intense,  salivation  is    considerable 


140    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

and  swelling  of  the  salivary  glands  and  ulceration  of  the 
gums  are  common. 

4.  It  is  dirty,  inconvenient,  and  very  difficult  to  have 
carried  out  with  anything  like  efficiency  under  ordinary 
circumstances.  That  it  is  dirty  goes  without  saying  ;  also 
it  is  undoubtedly  inconvenient  from  two  points — first 
because  it  necessitates  the  patient  giving  up  at  least  an 
hour  a  day  to  it,  and  secondly  it  is  compromising,  as  it 
stains  linen,  and  servants  and  washerwomen  soon  get  to 
know  what  is  going  on.  These  last  objections  may 
appear  trivial,  but  they  are  not,  as  one  soon  finds  out 
that  for  the  efficient  carrying  out  of  the  treatment  the 
patient's  feelings  form  an  important  factor.  That  it  is 
difficult  to  have  properly  carried  out  is  only  too  true, 
depending  as  it  does  on  the  capability  and  willingness  of 
the  rubber. 

Conclusion. — Until  recently  I  looked  on  the  inunction 
plan  as  the  most  efficacious  in  removing  certain  signs 
and  symptoms,  and  employed  it  extensively  in  cases  such 
as  for  the  removal  of  persistent  induration  at  the  site  of 
infection,  in  all  cases  of  syphilitic  sclerosis,  and  in  cerebro- 
spinal syphilis ;  but  at  the  present  time  intramuscular 
injections  of  calomel  have  quite  taken  the  place  of  inunc- 
tion in  my  practice  when  dealing  with  such  cases,  owing 
to  its  more  rapid  and  intensive  action. 

The  question  to  be  considered  is,  whether  the  inunction 
method  is  suitable  as  a  routine  form  of  treatment,  or 
whether  it  should  be  reserved  for  special  cases  ?  As  a 
routine  treatment  it  is  contra-indicated  first  because  the 
treatment   of  syphilis   is  not  a  symptomatic  one,  but  it 


TREATMENT  OF  SYPHILIS— INUNCTION  141 

aims  at  extinguishing  the  virus  both  as  a  diathesis  and 
as  a  possible  source  of  future  mishaps,  which  can  only 
be  realised  by  a  treatment  of  long  duration.  It  is  obvious 
that  the  inunction  method  is  not  suitable  for  this  purpose 
for  certain  reasons — i.e.  it  is  open  to  accidents,  as  already 
seen,  and  is  a  method  which  is  not  easily  carried  out  or 
agreeable  to  patients.  For  a  treatment  of  long  duration 
personal  and  social  necessities  must  be  taken  into  account, 
and  from  this  point  of  view  the  inunction  method  is  the 
most  inconvenient.  Undoubtedly  if  the  patient  tolerated 
inunction,  and  carried  it  out  faithfully  and  regularly  and 
for  the  whole  of  the  necessary  time,  I  am  certain  the 
result  would  leave  nothing  to  be  desired  ;  but  how  often 
is  such  a  patient  to  be  found  ?  As  a  routine  practice  the 
inunction  method  is  to  be  condemned :  it  runs  a  very 
good  chance  of  being  badly  performed ;  it  may  cause 
severe  stomatitis ;  it  is  repugnant  to  the  patient ;  it  may 
end  by  discouraging  and  disquieting  the  patient  with  the 
treatment,  and  cause  him  to  give  up  specific  treatment 
altogether. 

To  my  mind  the  inunction  method  should  be  reserved 
for  particular  cases :  cerebral  and  spinal  syphilis,  cases 
which  have  proved  refractory  to  other  methods,  cases 
of  syphilis  in  the  young ;  but,  with  the  exception  of  the 
last,  as  already  stated,  even  in  these  cases  injections  of 
calomel  have  taken  its  place. 


CHAPTER   XII 

TREATMENT   OF   SYPHILIS  (continued)— THE 
INTRAMUSCULAR   METHOD 

This  method  consists  of  injecting  certain  mercurial 
preparations  into  the  muscles,  with  the  view  to  their 
being  absorbed  by  the  circulatory  system. 

It  was  first  suggested  by  Scarenzio,  and  was  actively 
practised  for  a  certain  time :  owing  to  certain  accidents 
which  appear  to  have  almost  invariably  attended  it,  it 
had  to  be  abandoned.  The  history  of  this  method 
may  be  divided  into  three  periods:  (i)  the  period  of 
Scarenzio ;  (2)  the  period  of  Smirnoff ;  (3)  the  period  of 
Balzer. 

The  first  period  dates  from  1864,  when  the  treatment 
of  syphilis  by  subcutaneous  injections  of  calomel  was 
introduced  by  Scarenzio,  a  professor  in  the  University 
of  Pavia.  At  first  Scarenzio  used  yellow  oxide  of 
mercury,  and  later  on,  calomel ;  as  an  excipient  gly- 
cerine was  first  employed,  but  being  irritating,  gum- 
water  was  afterwards  substituted  for  it.  He  records 
having  given  eight  subcutaneous  injections  of  this,  each 
of  which  was  followed  by  an  abscess.  Ambrosoli  of 
Milan  published  a  series  of  sixteen  cases,  all  treated  by 

142 


INTRAMUSCULAR    TREATMENT  OF  SYPHILIS      143 

the  method  recommended  by  Scarenzio,  thirteen  of  which 
were  followed  by  an  abscess  after  each  injection.  Among 
the  opponents  of  this  method  we  find  Professor  Profeta, 
who  writes  of  it :  "  I  should  never  have  recourse  to  the 
method  unless  all  others  failed,  owing  to  the  constant 
occurrence  of  abscesses  at  the  site  of  injection."  In  spite 
of  these  accidents  the  method  continued  to  be  used  in 
most  of  the  capitals  on  the  Continent,  with  varying  fortunes 
in  each  country.  In  Italy,  although  it  had  some  very 
enthusiastic  exponents,  its  detractors  numbered  many 
men  ;  among  them,  as  already  seen,  was  Profeta.  Opinions 
concerning  it  were  divided  in  France.  At  the  St.  Louis 
Hospital  it  was  practised  with  much  success  by  Hardy ; 
and  Liegois,  substituting  sublimate  for  calomel,  was 
equally  successful.  On  the  other  hand,  Jullien  was  a 
strong  opponent  of  the  method.  In  England  the  system 
does  not  seem  to  have  been  practised  at  this  period  to 
any  extent ;  indeed,  there  is  little  proof  of  its  having  been 
tried  at  all.  In  Germany  and  Austria  opinions  differed 
concerning  it:  we  find  Stork  describing  it  as  a  "detest- 
able" treatment,  whilst  Kolliker  appears  to  have  been  in 
favour  of  it. 

In  three  or  four  years  the  method  had  gradually  died  out, 
and  we  hear  little  of  it  until  it  was  reintroduced  by  Smir- 
noff in  1882,  in  an  interesting  essay  on  the  subject  which 
was  published  in  that  year,  in  which  he  showed  that  with 
the  help  of  antiseptic  precautions,  which  by  this  time  had 
become  much  better  understood,  injections  could  be  given 
without  the  occurrence  of  abscesses.  Smirnoff  succeeded 
in    reviving   the   subcutaneous    method    for   a  time ;   and 


144    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

although  abscesses  became  much  rarer  than  formerly,  still 
they  were  frequent  enough  to  be  the  cause  of  the  method 
becoming  once  more  discredited. 

For  a  third  time  it  was  reviewed  :  Balzer  being  the 
means  of  doing  this  in  a  paper  which  he  read  before 
the  Societe  des  Hopitaux  on  May  n,  1888,  entitled 
"  Injections  of  Yellow  Oxide  of  Mercury  and  Calomel  in 
the  Treatment  of  Syphilis,"  in  which  he  explained  that 
the  chief  causes  of  abscesses  following  the  injections  were 
because  the  latter  were  given  into  the  subcutaneous  tissue 
instead  of  into  the  deep  tissues  ;  secondly,  owing  to  the 
unsuitability  of  the  vehicles  which  had  hitherto  been  in 
use.  To  remedy  these  defects  he  advocated  deep  injections 
into  the  muscles  and  the  substitution  of  liquid  paraffin 
as  a  vehicle  for  the  mercury  in  place  of  gum-water, 
glycerine,  and  olive  oil.  These  suggestions  were  followed 
by  the  best  results,  abscesses  became  rarer  as  time 
went  on,  and  the  intramuscular  method  became  established 
in  popular  favour  day  by  day  until  the  present  time, 
when  it  is  certainly  on  the  Continent  the  most  popular 
mode  of  treating  syphilis.  Curiously  it  never  seems  to 
have  been  taken  up  in  this  country  to  any  extent,  and 
even  in  England  to-day  and  in  her  world-wide  Empire 
it  is  little  known  certainly  amongst  the  civil  medical 
profession.  On  the  other  hand,  nowhere  is  the  intra- 
muscular treatment  more  popular  than  in  the  army,  into 
which  it  was  introduced  in  1889,  since  which  time  it 
has  been  steadily  gaining  in  favour  among  army  surgeons. 
Brilliant  results  have  attended  its  use,  especially  in  India, 
where  in  the  army  the  rates  of  invaliding  iand  death  from 


INTRAMUSCULAR    TREATMENT  OF  SYPHILIS    145 

syphilis  have  declined  to  about  two-fifths  of  what  they 
were  prior  to  the  introduction  of  the  intramuscular 
method. 

Advantages  of  the  Intramuscular  Method. — Like 
other  methods  of  administering  mercury,  the  intramuscular 
has  its  advantages  and  disadvantages,  which  must  be 
carefully  considered.  Taking  its  advantages  first,  the 
following  is  a  fairly  complete  list : 

1.  Convenience  to  the  patient. 

2.  It  insures  regularity  of  treatment. 

3.  It  leaves  the  stomach  free  for  the  reception  of  other 
remedies. 

4.  It  ensures  more  accurate  doses. 

5.  The  absorption  of  mercury  is  much  more  certain. 

6.  It  does  not  interfere  with  the  gastro-intestinal  system. 

7.  Less  chance  of  toxic  symptoms — stomatitis. 

8.  Both  therapeutic  intensity  and  physiological  effects 
are  much  more  marked  and  lasting. 

9.  It  does  not  exaggerate  the  moral  effect  of  the 
presence  of  syphilis  upon  the  mind  of  the  patient. 

As  regards  convenience,  I  think  it  must  be  admitted  that 
the  only  inconvenience  which  the  intramuscular  method 
entails  is  the  occasional  visit  of  the  patient  to  his  medical 
adviser  to  receive  his  injection ;  in  the  case  where  insoluble 
salts  are  used,  there  is  an  interval  of  at  least  a  week  and 
very  often  a  fortnight :  compare  this  with  his  having  to 
take  medicine  three,  four,  or  five  times  a  day  for  months 
at  a  time,  or  with  his  being  obliged  to  give  up  an  hour 
or  so  a  day  for  the  purpose  of  inunction  for  periods 
varying  from  a  month  to  six  weeks. 

10 


146    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

There  can  be  no  question  but  that  with  the  intra- 
muscular method  regularity  and  certainty  of  treatment 
is  assured,  and  with  it  there  is  no  fear  of  patients  eluding 
such.  This  is  a  most  important  consideration,  especially 
among  hospital  patients,  who,  owing  to  their  horror  of 
mercury,  often  do  everything  to  try  to  avoid  swallow- 
ing it. 

The  third  advantage  claimed  for  the  intramuscular 
method — i.e.  leaving  the  stomach  free  for  the  reception 
of  other  remedies  and  not  irritating  the  digestive  organs — 
is  true  ;  but  the  first  part,  avoiding  the  stomach,  is  not 
peculiar  to  it,  as  it  is  shared  by  the  inunction  method. 

As  regards  accuracy  of  dosage,  this  is  more  apparent 
than  real,  for  it  assumes  that  the  dose  absorbed  is  always 
the  same  as  that  injected  ;  and  although  I  believe  that 
in  the  majority  of  cases  this  is  true,  still  it  may  sometimes 
be  different — for  instance,  when  the  mercurial  deposit 
becomes  surrounded  by  inflammatory  tissue,  which  pre- 
vents its  absorption.  Speaking  generally,  it  will  be 
allowed  that,  although  not  quite  so  accurate  as  is  believed, 
the  dosage  of  mercury  given  by  injection  can  be  gauged 
far  more  accurately  than  that  given  by  either  ingestion 
or  inunction,  for  the  reason  that  in  the  former  case  the 
dose  of  mercury  which  can  reasonably  be  expected  to 
be  absorbed  is  known,  whereas  it  is  quite  unknown  in 
the  case  of  ingestion  or  inunction.  Absorption  of  mercury 
in  a  definite  manner  is  ensured  by  the  intramuscular 
method.  Already  we  have  seen  that  in  the  case  of 
ingestion  very  little  and  sometimes  no  mercury  may  be 
absorbed  ;    and    by   the   inunction    plan    the    amount   of 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     147 

absorption  must  of  necessity  be  very  uncertain,  depending 
as  it  does,  to  a  great  extent,  on  the  way  the  rubbing  is 
done. 

I  have  no  hesitation  in  saying  that  the  dangers  of 
toxic  effects  are  far  less  with  the  intramuscular  method 
than  with  other  plans,  especially  as  regards  stomatitis, 
provided  the  ordinary  precautions  are  adhered  to.  I 
do  not  mean  to  assert  that  this  never  occurs  ;  on  the 
contrary,  I  have  seen  cases  of  very  severe  stomatitis 
following  this  method,  although  very  rarely,  and  in 
my  opinion  in  this  respect  it  undoubtedly  compares 
most  favourably  with  the  methods  of  ingestion  and 
inunction. 

All  authorities,  even  those  who  oppose  the  intramuscular 
plan  of  giving  mercury,  are  agreed  as  to  its  superiority 
in  its  therapeutic  intensity  and  physiological  effects  on 
the  symptoms  of  the  disease.  In  this  respect  it  has 
undoubtedly  realised  expectations ;  it  is  acknowledged 
on  all  hands  to  be  a  powerful  form  of  mercurialisation, 
having  an  energetic  action  on  most  ot  the  manifestations 
ot  syphilis. 

With  regard  to  the  last  advantage  which  I  claim  for 
the  intramuscular  method — i.e.  its  not  emphasising  the 
moral  effect  of  the  presence  of  syphilis  on  the  mind  of 
the  patient — I  would  say  that  the  mental  condition  ought 
to  have  a  foremost  place  in  our  consideration.  Those  of 
highly-strung  disposition  are  liable  to  suffer  much  from 
depression  of  spirits  ;  the  mere  knowledge  that  they  are 
infected  induces  in  them  a  state  of  melancholy  bordering 
on  a  condition  known  as  syphilophobia,  and  this,  in  my 


148    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMEN1 

experience,  is  one  of  the  greatest  difficulties  met  with  in 
treating  syphilitic  patients,  especially  among  the  educated 
and  well-to-do  classes. 

The  first  thing  to  be  done  in  such  cases  is  to  endeavour 
to  divert  the  mind  from  the  exciting  cause.  This  we 
certainly  do  not  do  when  treating  the  disease  by  either 
the  method  of  ingestion  or  inunction,  for  when  a  patient 
has  to  take  a  pill,  powder,  or  medicine  three  or  four  times 
a  day,  or  to  be  daily  rubbed,  he  is  reminded  each  time  of 
the  "  skeleton  in  his  cupboard,"  whereas,  whilst  undergoing 
the  intramuscular  treatment,  this  reminder  need  only  be 
given  once  a  week,  or  even  fortnight.  This  advantage 
may  sound  a  trivial  one,  but  I  cannot  lay  too  much 
stress  on  it,  and  I  feel  convinced  that  it  has  helped  me 
over  many  difficulties;  for  with  the  mind  depressed 
treatment  of  any  kind  is  rendered  all  the  harder  to  carry 
out  to  a  successful  issue. 

The  Disadvantages  of  the  Intramuscular  Method. — 
The  disadvantages  of  the  intramuscular  method  are  said 
to  be  the  following  : 

i.  Pain  at  the  site  of  injection. 

2.  Nodosities  and  abscesses. 

3.  The  occurrence  of  embolism. 

Pain  at  the  site  of  injection  varies  in  different  subjects 
and  with  the  preparation  of  mercury  used ;  it  is,  in 
fact,  usually  present  when  the  soluble  salts  are  employed  ; 
whereas,  with  the  newer  preparations  of  the  insoluble 
salts,  even  calomel,  it  does  not  exist  to  any  extent.  I 
have  met  with  two  or  three  patients  who  complained  of 
severe  pain  after  injection,  but   those  were   neurasthenic 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     149 

subjects,  who  would  probably  make  a  similar  fuss  if 
ordered  to  take  medicine  internally  for  any  length  of 
time.  A  few  cases  complain  of  slight,  dull,  aching  pain, 
with  some  stiffness,  lasting  for  one  or  two  days ;  but  the 
majority  assert  that  pain  either  does  not  exist  at  all  or 
is  so  slight  as  to  be  insignificant. 

Nodosities  and  abscesses  are  things  of  the  past,  owing, 
no  doubt,  to  improved  technique.  The  former  may  cer- 
tainly be  sometimes  seen  even  now,  although  very  rarely. 
In  former  years  I  used  to  see  them  fairly  often,  but  now 
they  are  very  rare,  this  latter  circumstance  coinciding  with 
the  time  I  first  began  to  use  boiling  oil  as  a  steriliser 
for  needles  and  syringes.  In  my  opinion  the  occurrence 
of  abscesses  is  due  entirely  to  some  neglect  in  carrying 
out  the  technique.  As  regards  embolism,  although  cases 
are  reported  from  time  to  time,  I  have  never  seen  one 
in  my  long  experience  of  this  method. 

The  Two  Methods  of  Intramuscular  Injection. — The 
intramuscular  methods  are  of  two  kinds — the  frequent 
injection  of  soluble  salts,  and  the  infrequent  injection  of 
insoluble  salts. 

The  method  of  frequent  injections  consists  in  a  series 
of  mercurial  injections  practised  daily  for  five  or  six 
weeks.  The  preparations  used  for  this  purpose  are  nearly 
all  soluble.  The  list  of  these  preparations  is  innumerable, 
too  long  to  produce  here,  also  unnecessary ;  it  will  be 
sufficient  to  mention  the  principal  : 

Sublimate. 

Double  chloride  of  mercury  and  ammonium. 

Peptonate  of  mercury. 


150    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Tannate  of  mercury. 

Cyanide  of  mercury. 

Biniodide  of  mercury 

Lactate  of  mercury. 

Urate  of  mercury. 

Benzoate  of  mercury. 

Acetate  of  mercury. 

Sozoiodolate  of  mercury. 

Succinimide  of  mercury. 

Chloro-albuminate  of  mercury. 

Alaniate  of  mercury. 
All   the  above  are  mercury  served  up  under  different 
names,   and   from   such    a   list   of  remedies   it    might   be 
difficult  to  make  a  choice.     However,  the  following  are 
the  forms  in  which  they  are  generally  prescribed  : 

R  Hydrarg.  perchloridi     .         .        .     grs.  iij 

Aquae §j 

20  minims  as  a  dose,  by  injection. 

R  Hydrarg.  perchloridi     .  ■       .         .     grs.  xxxij 

Ammon.  chloridi  ....     grs.  xij 

Aquas gj 

Dose,  10  minims  for  an  injection. 

B=  Hydrarg.  succinimate   .         .         .     grs.  ij 

Cocainas  hydrochloridi  .         .         .     grs.  iij 

Aquas 3  ij 

Dose,  10  minims  for  an  injection. 

R  Hydrarg.  cyanidi  .         .         .         .     gr.  j 

Cocainas  hydrochloridi  .         .         .     gr.  j 

Aquae  destil n\  10 

Dose,  10  minims  for  an  injection. 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     151 

Peptonate  of  mercury  is  a  solution  in  glycerine  and 
water  of  a  mixture  of  peptone,  sublimate,  and  chloride  of 
ammonium  ;  it  contains  about  one  centigramme  of  bichloride 
in  a  centimetre  of  distilled  water,  and  is  said  to  be  better 
tolerated  than  sublimate. 

Benzoate  of  mercury  is  rendered  soluble  by  chloride 
of  sodium,  and  is  prescribed  thus  for  daily  injection: 

R     Hydrarg.  benzoat.  1  _ 

.  ,  > aa  gr.  f 

Ammon.  benzoat.     ) 

Aquae  destil 5  iss 

Biniodide  of  mercury  oil  was  introduced  by  Panas  : 

R     Hydrarg.  Biniodide. 
Olei  (sterilised). 

One  c.c.  contains  tV  grain  of  the  biniodide. 

Biniodide  is  an  active  and  safe  remedy,  is  well  tolerated 
as  an  injection,  and  causes  little  pain  or  local  trouble. 
Although  an  active  remedy,  it  is  one  of  only  medium 
intensity,  and  in  this  respect  cannot  compare  with  either 
calomel  or  metallic  mercury.  The  dose  recommended 
{i.e.  TV  grain)  is  too  small  to  produce  therapeutic  effects, 
for  which  purpose  at  least  \  grain  ought  to  be  injected. 
The  injections  of  biniodide  should  not  be  too  concen- 
trated ;  if  so  they  are  liable  to  produce  much  pain  and 
nodosities. 

Sozoiodolate  of  mercury  is  greatly  prescribed  for  in- 
jection purposes,  thus  : 

R     Sod.  iodi grs.  x. 

Hydrarg.  sozoiodol grs.  v. 

Aquae TT^  cc 

1^  x  to  TT^  xii  as  an  injection  four  or  five  times  a  week. 


152    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Like  many  of  these  preparations,  when  first  introduced  its 
praises  were  sung  very  loudly  ;  it  was  said  to  be  a  "  perfect " 
remedy,  free  from  any  semblance  of  pain,  and  possessing 
rapid  and  powerful  action  in  syphilis.  When  I  was 
accustomed  to  use  the  soluble  salts,  I  found  it  inferior 
to  almost  any  of  the  other  salts.  Its  therapeutic  intensity 
appeared  to  be  of  the  mildest  kind. 

Succinimide  of  mercury  has  also  been  highly  recom- 
mended, and,  indeed,  it  is  freely  used  even  now : 

&     Hydrarg.  succinim grs.  ij. 

Cocain.  hydrochl grs.  iij. 

Aquae ^  ij. 

T)|  x  as  an  injection  once  daily. 

Advantages  and  Disadvantages  of  Injection  of  the 
Soluble  Salts. — Although  at  one  time  opinions  were 
equally  divided  as  to  the  merits  of  injection  of  the 
soluble  salts  of  mercury  and  the  insoluble,  I  think  there 
can  be  little  doubt  that  at  the  present  time  the  advocates 
for  the  employment  of  the  former  are  very  few  in  com- 
parison with  those  in  favour  of  the  insoluble  salts.  At 
the  same  time  it  cannot  be  denied  that  the  daily  injec- 
tions of  the  soluble  salts,  especially  of  bichloride  or 
biniodide,  have  a  powerful  anti-syphilitic  action  ;  but  there 
they  end,  as  from  the  author's  experience  their  curative 
or  preventive  action  is  very  little.  In  other  words,  the 
soluble  salts  injected  daily  will  remove  the  ordinary 
active  early  symptoms  of  syphilis,  but  have  very  little 
effect  on  lesions  of  the  advanced  stages ;  and  although 
one  must  never  forget  that  recurrences  may  take  place 
after  the  very  best  treatment,  still  it  is  an  undoubted  fact 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     153 

that  they  are  far  more  common  after  a  course  of  the 
soluble  salts  than  after  one  of  inunction  or  injections  of 
the  insoluble  salts.  The  real  disadvantages  of  the  method 
of  frequent  injections  of  the  soluble  salts  are  : 

1.  The  injections  are  always  more  or  less  painful. 

2.  They    are    absorbed    too    rapidly,   and,   worse   still, 
eliminated  too  quickly. 

3.  They  require  to  be  injected  daily,  or  nearly  so. 
With  regard   to  the  pain,  although  this  is  never  very 

great,  still  it  is  much  more  so  than  when  the  insoluble 
salts  are  used,  and  when  I  was  accustomed  to  use  these 
soluble  salts  I  found  that  the  pain  they  caused  was  a  very 
great  obstacle.  As  already  seen,  it  has  been  claimed 
for  some  of  these  preparations  that  they  cause  little  or 
no  pain  ;  but  this  is  not  my  experience,  and  I  think  I 
have  employed  most  of  them.  That  their  absorption 
and  elimination  are  far  too  rapid  to  have  any  lasting 
effect  on  the  disease  goes  without  saying,  and  this  has 
become  all  the  more  apparent  since  the  discovery  of  the 
Spiroch&ta  pallida,  which  makes  its  reappearance  very 
soon  after  the  discontinuance  of  the  injections. 

The  third  disadvantage  of  the  soluble  salts  is  that  to 
be  effective  at  all  they  have  of  necessity  to  be  injected 
daily,  or  very  nearly  so.  From  a  practical  point  of  view 
this  is  a  great  obstacle  :  in  the  first  place,  the  patient 
not  being  able  to  give  an  injection  to  himself,  it  neces- 
sitates a  daily  visit  to  his  medical  adviser,  which  of  itself 
is  enough  to  condemn  the  method  ;  in  any  case,  the  vast 
majority  of  patients  will  object  strongly  to  having  an 
intramuscular  injection  daily. 


154    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

In  conclusion,  I  would  say  that,  although  formerly  I 
believed  that  the  frequent  injections  of  the  soluble  salts 
were  as  good  as,  if  not  superior  to,  the  insoluble  salts  in 
some  few  cases,  time  and  experience  have  taught  me  that 
I  was  wrong,  and  I  can  honestly  say  that  I  do  not  know 
of  any  case  in  which  they  are  not  infinitely  inferior  to 
the  latter,  and  that  as  a  method  of  routine  treatment 
they  cannot  be  put  on  the  same  level. 

THE  METHOD  OF  INFREQUENT  INJECTIONS 
OF   INSOLUBLE   SALTS 

This  method  consists  in  a  series  of  injections  of  insoluble 
salts  of  mercury  at  more  or  less  long  intervals.  The 
rationale  of  such  a  method  is  based  on  our  knowledge 
that,  with  a  view  to  prevention  and  cure,  syphilis  is  a 
disease  which  requires  the  administration  of  mercury  for 
a  period  of  at  least  two  years  intermittently,  but  in  such 
a  manner  that  the  patient  during  the  whole  period  is 
continuously  under  the  action  of  mercury.  Owing  to 
their  slow  absorption  and  elimination,  the  insoluble  salts 
are  selected  for  this  purpose. 

Forms  of  Insoluble  Salts  used. — The  two  chief 
preparations  of  mercury  which  are  used  for  carrying  out 
the  method  of  infrequent  injections  are  metallic  mercury 
itself  and  calomel,  besides  which,  although  not  nearly  so 
frequently  employed,  is  salicylate  of  mercury.  The  in- 
soluble salt  originally  used  was  the  yellow  oxide,  which 
has  long  been  superseded. 

Metallic  Mercury. — Metallic  mercury  for  the  treatment 
of    syphilis    by   intramuscular   injection   was    first   intro- 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     155 

duced  by  Lang,  of  Vienna.  He  brought  it  forward  in  the 
form  of  grey  oil  (oleum  cinereum),  which  is  a  mercurial 
preparation  consisting  of  mercury  in  a  state  of  fine 
division,  suspended  in  a  liquid  fat :  it  is  a  kind  of  liquid 
ointment,  and  contains  40  per  cent,  of  mercury. 

During  the  last  five-and-twenty  years  the  author  has 
used  metallic  mercury  in  preference  to  all  the  other  salts 
of  the  metal,  such  a  preference  being  arrived  at  after 
ample  opportunities  of  judging  them  side  by  side ;  and 
as  years  have  gone  on,  and  with  increased  experience,  his 
faith  has  grown  stronger  than  ever  in  it.  To-day  he  main- 
tains that,  although  its  therapeutical  intensity  is  certainly 
not  so  great  as  is  that  of  calomel,  its  curative  and  preventive 
effects  are  far  greater,  and,  as  a  consequence,  that  it  easily 
holds  premier  place  among  the  remedies  for  syphilis. 

The  Advantages  of  Metallic  Mercury. — The  advan- 
tages of  metallic  mercury  are  : 

1.  It  is  practically  painless. 

2.  It  is  slowly  absorbed  and  very  slowly  excreted. 

3.  It  is  less  likely  to  produce  stomatitis  than  other 
preparations. 

4.  It  requires  to  be  injected  only  at  long  intervals. 

5.  Therapeutic  effects  are  far  more  lasting  than  those 
of  any  other  preparation. 

There  is  little  doubt  but  that  injections  of  metallic 
mercury  are  peculiarly  free  from  pain  as  compared  with 
those  of  other  salts. 

It  is  owing  to  the  slowness  of  its  absorption  and  elimina- 
tion that  metallic  mercury  is  so  superior  in  its  lasting 
effects  to  the  other  preparations  of  mercury  in  the  treat- 


156    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

ment  of  syphilis ;  as  a  general  rule  it  may  be  said  that 
the  preparations  which  are  quickly  absorbed  are  quickly 
eliminated.  The  rate  of  absorption  of  mercury  given 
per  os  is  uncertain  ;  soluble  salts  of  mercury  given  by 
injection  are  quickly  absorbed  and  eliminated  ;  salicylate 
of  mercury  is  quickly  absorbed  and  eliminated  ;  calomel 
is  slowly  but  powerfully  absorbed,  and  eliminated  fairly 
quickly  ;  metallic  mercury  is  very  slowly  absorbed  and 
excreted. 

The  conclusion  come  to  as  regards  the  lasting  effects 
of  metallic  mercury,  has  been  further  strengthened  by 
observing  the  behaviour  of  the  Spirochceta  pallida  under  its 
influence.  At  the  Military  Hospital,  Rochester  Row,  it 
was  found  that,  although  those  organisms  disappeared 
with  about  the  same  rapidity  under  almost  any  form  of 
mercurial  injection,  they  reappeared  at  a  much  longer 
interval  after  the  discontinuance  of  the  metallic  prepara- 
tions than  was  the  case  under  a  similar  discontinuance 
of  any  other  form  of  mercury.  This,  needless  to  say,  is  a 
very  important  and  significant  fact,  and  a  strong  argument 
in  favour  of  the  metal  itself  in  the  treatment  of  syphilis. 

Gagniere  has  studied  the  modifications  in  the  blood 
caused  by  injections  of  metallic  mercury,  and  has  demon- 
strated that  the  corpuscles  and  the  haemoglobin  increase 
after  the  second  injection,  and  generally  diminish  after 
the  fifth.  It  is  accordingly  indicated  by  him,  not  to  give 
more  than  five  consecutive  injections. 

With  the  single  exception  of  calomel  the  therapeutic 
intensity  of  metallic  mercury  is  greater  than  that  of  any 
other  mercurial  preparation  ;  and,  although  inferior  in  this 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS      157 

respect  to  calomel,  it  is  not  only  far  better  tolerated 
than  that  salt,  but  is  far  better  than  it  as  regards  curative 
and  preventive  effects,  which  applies  equally  to  all  other 
preparations  of  mercury. 

Clinical  experience  taught  us  that  metallic  mercury,  by 
its  slow  absorption  and  elimination,  is  vastly  superior  to 
all  other  mercurial  remedies  in  its  lasting  influence  over 
syphilis — a  lesson  which  the  microscope  and  other  bacterio- 
logical researches  have  confirmed. 

It  is  needless  to  point  out  the  very  great  advantage  the 
insoluble  salts  have  over  the  soluble — i.e.  that  it  is  only 
necessary  to  give  injections  of  them  at  comparatively  long 
intervals — at  the  most  not  oftener  than  once  a  week. 
This  makes  the  plan  less  objectionable  to  the  patient. 

Preparations  of  Metallic  Mercury. — As  regards  the 
preparations  of  either  metallic  mercury  or  of  calomel, 
they  must  be  homogeneous  and  capable  of  being  injected, 
whilst  at  the  same  time  they  should  be  of  such  a  con- 
sistence as  to  be  able  to  hold  the  mercury  in  suspension. 
They  should  be  non-caustic,  unirritating,  and  sterile ;  they 
should  not  enter  the  organism  as  a  foreign  body,  and 
should  be  chemically  pure. 

The  preparations  of  metallic  mercury  which  have  been 
introduced  from  time  to  time  have  been  numerous.  Lang 
has  modified  the  formula  of  his  original  "  oleum  cinereum  " 
several  times,  the  latest  being : 

R 

Metallic  mercury    ......         2  parts 

Sterilised  anhydrous  lanolin   .         .         .         .         1  part 

Sterilised  liq.  paraffin 1     „ 

50  per  cent,  of  mercury.     Dose  gr.  §  of  mercury. 


158    SYPHILIS;    ITS  DIAGNOSIS  AND   TREATMENT 
Lafay's  formula : 

■    Metallic  mercury 40  parts 

Sterilised  anhydrous  lanolin  .         .         .         .       12     „ 
Sterilised  white  vaseline  .        .        .  13     „ 

Sterilised  oil  of  vaseline  .        .         .         .       35     „ 

40  per  cent,  of  mercury.     Dose  gr.  1  to  2  grs.  of  mercury. 

Author's  (original  formula)  : 

Pure  metallic  mercury 3  j 

Anhydrous  lanolin  .         .         .         .         .         %  iv 

Liquid  paraffin  (carbol.  2  %)  ad     .         .         .         3"  x 
By  volume  10  per  cent,  of  mercury.     Dose  10  to  15  minims. 

The  last  is  the  mercurial  cream  which  has  been  in  use 
throughout  the  British  Army  both  at  home  and  abroad 
during  the  past  ten  years  ;  and  although,  generally  speaking, 
it  has  given  great  satisfaction  and  has  yielded  brilliant 
results,  I  have  always  been  conscious  of  a  grave  objection 
to  which  it,  as  well  as  all  other  preparations  of  the  insoluble 
salts,  was  liable  :  it  is,  that,  owing  to  the  substances  which 
have  been  employed  in  them  as  vehicles  for  the  suspension 
of  the  mercury  being  insoluble  in  the  organism,  they 
entered  the  circulation  as  foreign  bodies^  and  as  such 
might  possibly  produce  nodosities,  abscesses  and  embolism. 
To  overcome  this  grave  objection  had  for  years  been  my 
endeavour,  until  I  eventually  attained  my  object  by  sub- 
stituting "  palmitin  "  as  the  vehicle  in  place  of  lanolin. 

Palmitin *  is  a  neutral  fat  derived  from  palm  oil,  having 

1  In  Stirling's  work  on  Physiology,  p.  29,  it  is  stated  that  neutra 
fats  of  adipose  tissues  of  the  body  generally  consist  of  a  mixture 
of  stearin,  olein,  and  palmitin.      Prof.   Halliburton,   in  "  Essentials 
of  Chemical  Physiology,"  p.  15,  states  that  the  fat  cells  are  composed 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     159 

the  same  chemical  composition  as  the  palmitin  of  the 
human  system.  It  is  an  ether  glycerine  of  palmitic  acid, 
is  therefore  easily  saponified  in  the  fluids  of  the  organism, 
being  converted  into  a  soluble  alkaline  palmitate  and 
glycerine,  and  thus  it  enters  the  circulation  not  as  a 
foreign  body,  like  all  substances  hitherto  employed  as 
vehicles.  The  advantages  claimed  for  palmitin  as  a 
vehicle  are  : 

1.  It  is  non-irritant  and  non-toxic. 

2.  It  is  not  so  easily  oxidised  as  the  other  compounds 
of  human  fat. 

3.  Being  already  a  normal  constituent  of  the  human 
organism,  it  is  easily  saponified  and  soluble  therein,  and 
does  not  enter  the  circulation  as  a  foreign  body. 

4.  As  a  vehicle  it  makes  a  more  homogeneous  prepara- 
tion for  injection  purposes  than  any  other. 

5.  Its  melting-point  can  be  raised  or  lowered  with  the 
greatest  facility. 

Pure  palmitin  (which  is  the  only  preparation  used)  is  a 
snowy-white  flocculent  powder,  and  great  care  is  necessary 
to  get  it  pure. 

Analgesia. — The  question  of  pain,  although  never 
amounting  to  anything  serious  so  far  as  metallic  mercury 
is  concerned,  still  has  been  sufficient  to  constitute  a  grave 
objection  to  the  practice  of  intramuscular  injections  of 
mercury,  and  is  apt  to  bring  about,  what  Fournier  terms 

of  three  different  fats  called  palmitin,  stearin  and  olein.  Charles, 
"  Physiology  and  Pathology,"  p.  84,  says,  palmitin  is  more  abundant 
than  stearin  in  human  fats,  and  is  the  chief  component  of  most 
animal  fats. 


160    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

"  fear  of  the  needle,"  with  consequent  desertion  and  non- 
attendance  for  further  injections  on  the  part  of  patients  ; 
in  the  case  of  calomel  pain  used  to  be  the  chief  objection 
to  its  use  for  injection  purposes. 

With  a  view,  if  possible,  to  abolish  pain  altogether  after 
injections,  various  substances  have  been  introduced  from 
time  to  time  into  the  mercurial  preparations  used  for  that 
purpose — i.e.  morphia,  cocaine,  /3-cocaine,  etc.  ;  these, 
acting  as  they  do  almost  at  once,  will  assuage  any  pain 
which  may  follow  immediately  after  the  injection.  But 
unfortunately,  this  is  not  the  kind  of  drawback  we  have  as 
a  rule  to  deal  with,  as  the  pain  which  troubles  us  is  one 
which  comes  on  the  second  or  third  day  after  the  injection, 
when  all  local  anaesthetics  like  the  above  are  useless.  This 
is  a  very  serious  matter,  but  more  so  as  regards  injections 
of  calomel,  for  the  pain  is  most  marked  and  severe  with 
this  drug.  The  consequence  was  that  hitherto,  not  being 
able  to  cope  with  it,  injection  of  calomel  had  to  be 
abandoned  and  only  resorted  to  in  some  grave  case  where 
pain  was  a  matter  of  secondary  consideration  ;  thus  per- 
haps our  strongest  weapon  for  dealing  with  syphilis  was 
practically  lost  to  us. 

To  obviate  this  pain,  I  added  to  my  latest  mercurial 
preparation  equal  parts  of  absolute  creosote  and  camphoric 
acid — a  combination  which  has  proved  altogether  a  com- 
plete success,  as  it  renders  the  injections  even  of  calomel 
quite  painless.  This  combination  of  creosote  and  cam- 
phoric acid  possesses  other  attributes  :  i.e.  it  is  non-toxic, 
strongly  antiseptic,  and,  being  viscid,  is  a  valuable  adjuvant 
to  the  palmitin  in  making  up  a  homogeneous  vehicle. 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     161 
The  following  is  the  formula  for  the  metallic  cream  : 

&     Hydrarg.  pur io  grms. 

Creo-camph.1         .....         20  c.c. 
Palmitin  bases  ad 100  c.c. 

T(\_  x  contain  1  grain  of  metallic  mercury. 

The  greatest  care  ought  to  be  exercised  in  seeing  that 
the  cream  is  of  proper  consistence.  It  should  be  kept  in 
wide-mouthed  glass  bottles,  and  only  removed  from  them 
when  required  for  injection  purposes.  No  attempt  should 
be  made  to  sterilise  the  cream,  as  it  is  already  sterile;2 
before  use  it  should  be  well  stirred  up  with  a  glass  rod. 
In  cold  climates  the  cream  is  liable  to  become  semi-solid, 
and  it  may  require  slight  heating  in  a  warm-water  bath ; 
in  the  tropics  the  reverse  occurs,  and  there  the  bottle  con- 
taining the  cream  should  always  be  kept  in  an  ice-chest 
until  it  is  required  for  use,  when  it  can  be  transferred 
to  some  crushed  ice. 

It  is  advisable  that  the  melting-point  of  this  cream 
should  be  regulated  to  suit  the  climate.  In  the  case  of 
the  cream  used  in  England  at  present,  we  find  350  centi- 
grade the  best ;  in  the  creams  sent  to  the  tropics,  it  is 
raised  by  30  centigrade. 

Disadvantage. — Metallic  mercury  has  only  one  real 
disadvantage,  which  is,  that  should  salivation  take  place 
after  an  injection  it  is  a  difficult  matter  to  prevent  matters 
getting  worse,  unless   the   mercury   can   be   removed   by 

1  Equal  parts  of  absolute  creosote  and  camphoric  acid. 

2  Leishman  reports  that  "this  preparation  is  sterile  and  bacteria 
will  not  grow  in  it." 

II 


r62    SYPHIUS:    ITS  DIAGNOSIS  AND    TREATMENT 

operation.  I  have  never  seen  a  case  requiring  so  severe 
a  measure,  and  cannot  help  thinking  that  the  reported 
cases  were  the  victims  of  too  large  a  dose ;  so  long  as 
the  latter  does  not  exceed  ih  gr.  per  week  these  cases 
will  not  occur. 

Calomel. — Calomel  has  long  ago  proved  itself  to  be 
the  most  potent  salt  of  mercury  in  its  power  over  syphilis 
in  all  its  stages.  It  is  more  active  and  energetic  than 
any  other  preparation  of  mercury,  acting  promptly  in 
acute  cases,  as  well  as  clearing  up  old-standing  ones. 

In  spite  of  this,  as  already  stated,  owing  to  the  pain 
which  followed  calomel  injections,  it  has  been  limited  to 
the  treatment  of  certain  special  cases. 

This  pain  at  times  was  almost  intolerable,  and  at  one 
period  I  used  to  give  injections  of  calomel  with  much 
hesitation,  reserving  them  for  exceptional  cases  where 
symptoms  were  of  such  urgency  that  pain  could  not  be 
taken  into  account.  However,  by  the  help  of  the  com- 
bination of  creosote  and  camphoric  acid  (already  described) 
the  pain  has  been  entirely  overcome,  and  for  the  past 
three  years  I  have  been  using  calomel  with  impunity. 

The  following  is  the  formula  for  calomel  cream  : 

R        Calomel  purified 5  grms. 

"  Creo-camph."  ' 20  c.c. 

Palmitin  bases  ad 100  c.c. 

V[  x  equals  calomel  \  gr.      Dose  17^  x  t0  xv  Per  week. 

Calomel  and  Metallic  Mercury. — It  has  been  observed 
long  ago  by  others,  as  well   as  by  the   author,  that   the 
action    of     calomel     on    syphilis,    although     remarkably 
1  See  footnote,  p.  161. 


INTRAMUSCULAR   TREATMENT  OF  SYPHILIS     163 

energetic  and  rapid,  is  short-lived  when  compared  with 
that  of  metallic  mercury.  Hence  it  will  never  take  the 
place  of  the  latter  in  the  routine  treatment  of  the  disease, 
but  will  be  reserved  more  for  dispersing  early  symptoms 
and  signs  of  the  disease,  and  for  those  cases  where 
symptoms  call  for  rapid  action,  i.e.  cerebral  and  spinal 
syphilis,  etc.  Even  in  such  cases  metallic  mercury  will 
have  to  be  reverted  to,  to  effect  a  permanent  alleviation. 


CHAPTER   XIII 

TECHNIQUE  OF  THE  INTRAMUSCULAR 
METHOD 

The  technique  of  the  intramuscular  method  of  introducing 
mercury  into  the  organism  is  simple,  but  the  following 
rules  concerning  it,  although  some  may  appear  too  insigni- 
ficant to  be  remembered,  are  all  of  the  greatest  importance, 
and  should  be  strictly  adhered  to. 

Instruments. — i.  The   syringe  should   be   all  glass,  so 
that  it  can  be  sterilised  throughout. 

2.  The  needles  must  be  of  either  platino-iridium  or  gold  : 
maximum  length  i£  in. 

3.  The   points   of  the   needles  to  be  kept  as  keen    as 
possible,  to  facilitate  penetration  and  thus  lessen  pain. 

4.  Steel   needles   not  to   be   used,  as  they  are  apt   to 
snap. 

5.  Both  needles  and  syringe  to  be  thoroughly  sterilised 
in  oil  heated  to  1600  F. 

6.  "  Injections  to  be  given  into  the  muscles,"  and  not 
subcutaneously. 

7.  The  skin  over  the  site  of  injection  to  be  swabbed 
over  with  some  antiseptic  solution  prior  to  puncture. 

8.  A  cloth,  wrung  out  of  carbolic  acid  solution   1  in  20, 

to  be  spread  on  a  table  to  lay  the  syringe  on. 

164 


TECHNIQUE   OF  THE  INTRAMUSCULAR  METHOD     165 

9.  No  cotton  wool  or  anything  "  fluffy  "  to  be  brought  near 
or  used  to  wipe  the  needles,  pieces  of  sterilised  linen  or 
gauze  being  used  for  this  purpose. 

10.  The  best  sites  for  injection  are  (1)  npper  third  of 
buttock ;  (2)  the  retro-trochanteric  fossa ;  (3)  the  lumbar 
muscles. 

11.  The  operation  of  injection  to  be  completed  in  one 
stage. 

12.  In  the  case  of  the  insoluble  salts  of  mercury 
injections  should  be  given  at  most  once  a  week. 

Salicylate  of  Mercury. — The  salicylate  of  mercury  is 
used  on  a  large  scale  on  the  Continent,  especially  in 
Germany.  For  some  time  I  employed  it  fairly  extensively, 
giving  \  gr.  suspended  in  liquor  paraffin,  twice  a  week, 
but  on  the  whole  found  it  very  inferior  to  either  mercury 
or  calomel. 

SOME  POINTS  TO  BE  CONSIDERED  IN 
THE  TREATMENT  OF  SYPHILIS  BY  THE 
INTRAMUSCULAR    METHOD 

As  to  dosage,  no  definite  rule  can  be  laid  down,  for, 
as  already  pointed  out,  each  patient  tolerates  mercury  to 
a  different  degree.  What  the  latter  is  can  only  be  arrived 
at  by  a  personal  study  of  each  individual  case  ;  hence 
the  great  necessity  of  treating  cases  on  their  merits. 

The  following  circumstances  govern,  to  a  great  extent, 
the  dosage : — 

1.  The  type  of  syphilis:  as  pointed  out,  the  dose  of 
mercury  which  will    dissipate  an    ordinary  roseolar   rash 


166    SYPHILIS:    ITS   DIAGNOSIS  AND   TREATMENT 

will  probably  have  no   effect    on   a   papular   or   pustular 
eruption. 

2.  The  condition  of  the  patient :  a  strong,  healthy 
individual  will,  as  a  rule,  require  a  larger  dose  than  a 
weakly  one. 

3.  Cases  of  "malignant"  or  "virulent"  syphilis  require 
smaller  doses  than  ordinary  ones. 

Maximum  Dose. — Of  the  metallic  mercurial,  I  find 
that  the  maximum  dose  should  not  exceed  ij  gr.,  or 
r\.  xv  of  the  cream.  I  get  far  better  results  using  this 
reduced  dose  than  I  formerly  did  when  employing  the 
larger  ones.  The  fact  is,  that  under  large  doses  of  mercury 
the  blood  after  a  time  deteriorates,  but  that  when  smaller 
doses  are  given  the  metal  acts  as  a  blood  tonic. 

The  maximum  dose  of  calomel  which  I  give  is  f  gr. 
(v\  xv  of  the  calomel  cream) ;  this  is  given  once  a  week, 
and  is  seldom  continued  longer  than  the  fourth  injection, 
when  metallic  cream  is  resorted  to. 

Treatment  should  be  of  an  intermittent  character — 
that  is,  injections  should  be  given  in  courses,  with  certain 
intervals  when  none  are  given  ;  these  "  rest-intervals " 
being  gradually  increased  in  length  as  the  case  goes  on. 

Although  no  arbitrary  rule  can  be  laid  down  as  to 
dose,  intervals  between  injections,  intervals  of  rest  and 
length  of  treatment,  it  is  a  safe  and  prudent  proceeding 
to  have  a  certain  plan  to  follow,  and  this  is  my  own. 

PLAN 

1.  A  course  of  six  weeks'  treatment,  which  involves 
six  mercurial  injections  (four  of  which  are  calomel). 


TECHNIQUE   OF  THE  INTRAMUSCULAR  METHOD      167 

2.  Two  months'  interval  without  injections. 

3.  Two  months'  treatment:  eight  mercurial  injections 
(metallic). 

4.  Four  months'  period  of  rest 

5.  Two  months'  treatment :  eight  mercurial  injections 
(metallic). 

6.  Six  months'  period  of  rest. 

7.  One  month's  treatment  :  four  mercurial  injections. 

8.  Four  months'  period  of  rest. 

9.  Two  months'  treatment :  eight  mercurial  injections. 
In    giving    this    tabular   statement    it   cannot   be    too 

strongly  impressed  on  the  reader  that  it  is  absolutely 
impossible  to  lay  down  any  stock  plan  of  dealing  with 
a  disease  like  syphilis. 

In  former  years  it  was  my  custom  to  begin  treatment 
with  inunction  of  mercury  (30  rubbings  a  l'Aix)  ;  but 
now  that  I  am  enabled  to  use  calomel  with  impunity 
I  begin  the  treatment  with  it  in  preference  to  inunction, 
as  there  is  no  comparison  between  the  two  as  regards 
rapidity  and  energy  of  action ;  after  four  injections  of 
calomel  I  resort  to  metallic  mercury,  which  is  probably 
employed  during  the  remainder  of  the  treatment. 

How  Long  should  Treatment  be  continued? — Al- 
though one  can  never  say  for  certain  how  long  treat- 
ment should  be  continued,  or  when  a  patient  can  be 
considered  cured  of  his  disease,  still  treatment  cannot 
go  on  for  ever,  and  a  decision  will  most  certainly  be 
asked  for  and  will  have  to  be  given  sooner  or  later. 
Up  to  recent  years  the  only  means  we  had  to  enable 
us    to    form     a    definite    opinion    on    this    subject   was 


1 68    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

long  experience  of  treatment  and  observation  of  numbers 
of  cases ;  however,  the  introduction  of  Wassermann's 
reaction  test  bids  fair  to  put  us  in  a  far  stronger  and 
better  position  in  coming  to  a  definite  decision  as  to 
whether  a  case  may  be  considered  cured  or  not :  and 
I  think  we  have  every  right  to  believe  that  a  case  which 
has  had  two  years'  thorough  treatment,  and  which  at  the 
end  of  that  time  gives  repeated  negative  reactions  with 
Wassermann's  test,  is  one  which,  to  say  the  least,  needs  no 
further  treatment.  As  regards  this  test,  one  cannot  help 
feeling  that  its  importance  in  solving  the  questions  of 
"  how  long  should  treatment  be  continued,"  or  "  when  the 
patient  may  be  considered  cured  "  cannot  be  exaggerated. 

Precaution. — It  is  unnecessary  to  say  that  before  the 
injection  of  mercury  is  given  all  the  precautions  as 
regards  the  hygiene  of  the  mouth  and  teeth,  as  already 
described  (p.  113),  should  be  rigidly  adhered  to. 

Contra-indications  to  Mercury. 

Albuminuria. — Many  cases  of  syphilis  exhibit  albu- 
minuria in  their  early  stages,  due  probably  to  tubal 
nephritis  of  a  syphilitic  nature,  which  will  disappear 
under  mercury.  On  the  other  hand,  the  metal  must 
be  given  carefully  and  in  reduced  doses  where  organic 
disease   of  the  kidneys  is  due  to  some  other  cause. 

Malaria  adds  very  much  to  the  seriousness  of  an 
attack  of  syphilis,  as  patients  suffering  from  it  stand 
mercury  badly  and  become  easily  salivated.  Before  being 
subjected  to  mercury  such  patients  should  have  a  thorough 
course  of  quinine. 


TECHNIQUE  OF  THE  INTRAMUSCULAR  METHOD     169 

OTHER    METHODS    OF    ADMINISTERING 
MERCURY 

Fumigation  was  used  frequently  in  days  of  yore,  but 
fell  into  disrepute  for  many  years  until  it  was  partially 
revived  by  Henry  Lee.  It  is  little  practised  now,  as  it 
often  produces  salivation,  anaemia,  and  general  debility. 

Intravenous  Injection,  introduced  by  Baccelli  in  1893, 
consists  of  the  introduction  of  mercury  into  the  circu- 
lation through  a  vein ;  the  advantages  claimed  being 
that  it  is  painless,  and  that  physiological  effects  are 
brought  about  much  quicker  than  when  other  methods 
are  employed.  The  objections  to  it  are  difficulties  of 
technique,  thrombosis,  embolism,  and  phlebitis. 

Zittmanri s  Treatment  consists  of  treating  chronic  and 
refractory  cases  of  syphilis  by  eliminating  the  poison  from 
the  system  by  sweating,  purging,  and  the  administration 
of  mercury  in  infinitesimal  doses,  the  latter  being  com- 
bined with  tonic  decoctions.  The  course  of  treatment 
lasts  fourteen  days,  during  which  time  the  patient  is 
kept  in  a  temperature  of  8o°  F. 


CHAPTER  XIV 

FURTHER  DEVELOPMENTS  IN  THE  TREAT- 
MENT OF  SYPHILIS,  INCLUDING  THE 
"  EHRLICH-HATA-No.  606   PREPARATION  " 

As  a  result  of  the  beneficial  effects  which  had  been 
obtained  from  the  use  of  "  Atoxyl"  in  Sleeping  Sickness, 
and  from  his  own  researches  as  regards  its  action  in  fowl 
spirillosis,  Uhlenhuth  suggested  that  the  same  drug  might 
be  useful  in  Syphilis,  the  latter  being,  like  Trypanosomiasis, 
a  protozoal  disease.  Hallopeau  and  Salmon  in  France 
and  the  author  in  England  made  experiments  according  to 
this  suggestion  with  much  success,  other  observers  also 
reporting  favourably  on  it.  On  the  other  hand,  from 
different  sources  came  records  showing  symptoms  of 
toxicity  from  its  use — i.e.  gastro-intestinal  pains,  malaise, 
nausea,  and  vomiting,  and  more  serious  still,  of  total  blind- 
ness from  optic  atrophy.  These  adverse  reports  resulted 
n  Atoxyl  being  dropped ;  in  England  in  its  place  a 
preparation  of  arsenic  named  Soamin  (para-amino-phenyl- 
arsonate)  was  adopted  ;  this  is  analogous  to  Atoxyl,  but  is 
a  known  staple  preparation.  It  had  one  great  disadvantage 
— i.e.  that  its  solutions  decomposed  on  keeping,  and  were 

thus  rendered  dangerous. 

170 


FURTHER  DEVELOPMENTS  IN  THE   TREATMENT   171 

Dose. — Given  by  intramuscular  injection,  I  gave  10  grs. 
every  other  day  until  a  total  of  100  grs.  had  been  given, 
and  the  course  was  repeated  in  a  month's  time  with  this 
preparation.  I  had  much  success  in  the  early  stages  of 
syphilis,  more  especially  in  cases  with  mouth  and  throat 
lesions. 

"  Arsacetin  " 

The  next  Arylarsonate  preparation  used  was  "Ar- 
sacetin," introduced  by  Ehrlich.  This  was  spoken  of 
very  highly  by  Neisser  before  the  Dermatological  Clinic 
at  Breslau.  Arsacetin  is  described  as  Sodium  Acetyl- 
phenyl-arsonate.  Of  this  Neisser  says,  "In  accordance  with 
this  experience  gained  with  animals,  we  have  now  for  some 
months  treated  the  greater  number  of  our  syphilis  patients 
with  Arsacetin,  and  I  believe  that  I  can  recommend  it  as  a 
very  useful  preparation."  In  the  writer's  hands  it  proved 
a  great  success  in  some  two  hundred  cases  of  both  early 
and  late  syphilis. 

Dose. — Given  intramuscularly  in  10  per  cent  and  15  per 
cent  solutions  in  courses  of  100  grs.,  like  Soamin.  Its 
great  advantage  is  that  its  solutions  never  decompose. 


Arseno-phenyl-glycin 

Another  preparation,  also  introduced  by  Ehrlich,  is 
Arseno-phenyl-glycin.  This  preparation  was  proved  to  be 
the  most  highly  trypanocidal  of  all  Arylarsonates,  and  it 
was  hoped  that  it  would  prove  equally  so  to  the  SpirochcBta 
pallidum.     These  hopes  have  not   been    fulfilled,  and  in 


172    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

the  author's  estimation  it  is  not  nearly  so  efficacious  as 
Arsacetin ;  besides,  it  has  the  great  disadvantage  that 
exposure  to  air  causes  decomposition,  when  the  drug 
becomes  poisonous. 

Conclusions  as  regards  Arylarsonates 

That  the  Arylarsonates  have  a  distinct  specific  effect 
in  clearing  up  syphilitic  symptoms,  both  in  early  and 
late  syphilis,  there  can  be  no  doubt  whatever,  and  up 
to  within  eighteen  months  ago  one  had  much  hope  of 
their  being  able  to  effect  a  final  cure  ;  however,  since 
Wasserman's  reaction  test  became  more  familiar  to  us, 
this  assumption,  to  say  the  least,  has  become  doubtful. 
It  is  found  that  whereas  in  many  cases  they  do  not 
appear  to  affect  the  reaction  at  all,  in  others  a  negative 
one  is  brought  about  much  more  slowly  when  they  are 
used  than  is  the  case  when  mercury  is  employed,  and 
what  is  of  still  more  significance  is  that  a  positive  reaction 
returns  very  quickly  after  their  discontinuance. 

"  Hata,"  or  No.  606 

Ehrlich,  who  has  been  the  foremost  worker  for  years 
in  the  study  of  the  curative  values  of  innumerable  syn- 
thetic organic  bodies,  observes  "  that  it  is  not  an  unusual 
phenomenon  that  a  substance  which  is  inimical  to  an 
organism  in  a  large  dose  is  favourable  to  its  growth  in 
a  small  one,  and  in  those  instances  in  which  a  '  contrary 
effect '  is  observed,  the  quantity  of  the  chemical  reagent 


FURTHER  DEVELOPMENTS  IN  THE   TREATMENT    173 

which  the  parasite  fixes  is  so  small  that  it  is  sufficient 
to  stimulate  it,  but  not  to  destroy  it."  Ehrlich  therefore 
inclines  to  his  "  Therapia  magna  sterilans."  He  would 
introduce  into  the  body  one,  and  only  one,  massive  dose 
of  the  parasitotropic  chemical  substance,  which  would 
free  it,  once  and  for  all,  from  its  invading  parasitic  foes." 
With  this  object  in  view  he  has  introduced  the  now 
well-known  preparation  dioxy-diamido-arseno-benzol  ;  this 
has  been  investigated  by  Hata,  hence  it  is  called  by  his 
name,  or  by  the  number  606,  for  which  the  following  is 
the  formula  : 

Oh/        )As  =  As/^    \0H 
NH2  NH2 

"  Hata  "  appears  as  a  yellowish  powder,  and  each  dose 
is  contained  in  a  glass  capsule  sealed  in  vacuo.  Before 
commencing  treatment  by  No.  606  the  patient  should 
be  kept  in  bed,  a  pulse  and  temperature  chart  kept,  and 
every  means  taken  to  ascertain  whether  the  patient  is 
free  from  degeneration  of  liver  and  kidney. 


Method  of  Administering  the  Drug 

The  method  adopted  for  the  preparation  of  the  emulsion 
of  "  Hata "  at  the  Military  Hospital,  Rochester  Row, 
London,  is  as  follows :  0'6  gramme  of  the  powder  is 
shaken  into  30  c.c.  of  sterile  water  heated  to  500  C.  con- 
tained in  a  sterile  vessel.     Solution  is  effected  with   the 

N 
aid  of  a  glass  rod  ;  6  c.c.  of  — ,  NaOH  are  slowly  added 


174A    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 
— a  lumpy  precipitate  falls,  which  re-dissolves  in  the  excess 

N 
of  the  alkali.     —  acetic  acid  (prepared  by  mixing  I  c.c.  of 

glacial  acetic  acid  with  i6'6  c.c.  of  sterile  water)  is  dropped 
in  until  neutrality  is  restored  ;  3*25  c.c.  is  the  theoretical 

N 
amount   of  —  acid  required.     The  "  Hata "  salt  is   again 

precipitated,  but  this  time  in  a  very  fine  form,  which  can 
pass  with  ease  through  the  needle  of  the  syringe.  By 
using  the  exact  quantities  given  above,  the  "  606 "  be- 
comes suspended  in  a  solution  of  sodium  chloride  and 
acetate,  which  is  isotonic  with  physiological  saline  fluid — 
pain  is  thereby  avoided.  The  whole  is  then  injected 
either  into  the  glutei  or  subcutaneously  beneath  the 
scapula.  The  pain  of  the  injection  is  trifling  at  the  time, 
but  shortly  afterwards  may  be  severe.  On  the  third  or 
fourth  day  it  may  be  aggravated  by  the  infiltration 
which  is  produced  ;  this  may  be  relieved  by  warm  baths 
and  fomentations,  but  morphia  is  sometimes  required. 

The  temperature  as  a  general  rule  rises  to  ioo°  F.  on 
the  night  of  the  injection,  to  become  normal  after  48  hours. 
In  a  number  of  cases  induration  remains  for  some  time  at 
the  site  of  injection. 

With  regard  to  "  Hata "  in  the  treatment  of  syphilis, 
Neisser  has  given  the  following  pronouncement : — 

"I  have  injected  'Hata'  in  126  cases,  and  find  that 
the  preparation  is  very  highly  spirochsetetropic.  In  almost 
every  instance  where  manifest  lesions  existed,  the  lesions 
subsided  in  a  startling  manner.  Primary  sores  lost  their 
hardness  and  healed,  whilst  the  Treponemata  in  Chancre 


FURTHER  DEVELOPMENTS  IN  THE  TREATMENT  174B 

and  Condylomata  disappeared  in  twenty-four  hours.  Mus- 
cular and  papular  eruptions  became  stains  in  a  day  or  so. 
Mucous  patches  went  ;  shotty  glands  subsided  ;  gummata 
melted  away  ;  tertiary  ulcers  of  malignant  syphilis  cleaned 
and  cicatrised  in  a  few  days ;  the  paralyses  and  pains  of 
cerebral  syphilis  disappeared  sometimes  in  an  hour  or  so." 


Action  in  the  Wasserman  Reaction. 

As  to  the  influence  of  the  new  remedy  in  changing 
a  positive  Wasserman  reaction  into  a  negative,  Neisser 
observed  this  in  44  per  cent  of  his  cases.  Gerome  found 
negative  reactions  in  60  per  cent  of  his  ;  Schruber  in 
80  to  90  per  cent ;  and  Wechselmann  in  100  per  cent  of 
his.  In  270  cases  treated  with  "Hata"  by  Lange,  57 
per  cent  reacted  negatively  four  or  five  weeks  after  the 
treatment. 

McDonald  reporting  on  20  cases  treated  by  "  Hata " 
says :  "  Beyond  the  improvement  observed  by  the  naked 
eye,  I  was  very  much  struck  by  the  extraordinary  change 
for  the  better  in  almost  every  patient's  general  condition  ; 
they  not  only  appeared  brighter,  but  felt  ever  so  much 
better  and  put  on  weight." 

Toxicity. — Neisser  states  that  2,500  patients  have  been 
treated  with  "  606  "  without  any  toxic  effects,  and  disorders 
of  vision  and  optic  atrophy  have  never  been  observed. 

Final  Remarks. — At  the  Frankfort  Congress  of  the 
German  Dermatological  Society  in  1907,  Ehrlich  when 
introducing  "  Arsacetin "  as  an  improved  remedy  for 
Syphilis,  remarked  thus : 


I74-C    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

"  But  even  if  this  material  should  prove  unsuitable  for 
human  use,  we  must  not  throw  up  the  cards  and  abandon 
hope  of  something  better.  Then  must  we  advance  further 
along  the  road  which  now  stretches  clear  before  us." 

True  to  this  advice,  Ehrlich  has  continued  the  hard  fight 
until  he  is  about  to  reap  his  reward  by  producing  "  Hata  " 
or  "  No.  606,"  which  apparently  has  a  wonderful  future 
before  it  in  the  treatment  of  Syphilis. ' 


ARYLARSONATE  AND   OTHER  METHODS  175 

AUXILIARY   MEANS   OF   TREATMENT 

Although  mercury  and  the  arylarsonates  form  the  main 
part  of  the  treatment  of  syphilis,  there  are  auxiliary  means 
which  are  also  very  necessary — viz.  hydrotherapy,  iodide 
of  potassium,  and  various  tonics ;  besides  these  care  in 
living  and  dieting  is  most  desirable. 

Second  only  to  specific  medication  do  I  consider  hydro- 
therapy, for  hot  baths  of  all  kinds  favour  the  elimination 
of  mercury,  and,  what  is  of  greater  importance,  increase 
and  maintain  metabolism  generally.  Hot-air  baths  are 
best,  then  Turkish  baths,  and  last  hot-water  baths.  At 
Rochester  Row  every  patient  undergoing  either  mercurial 
or  arylarsonate  treatment  for  syphilis  sits  in  a  hot-air 
bath  at  a  temperature  of  300  °  daily  for  ten  minutes. 

Iodide  of  Potassium. — Iodide  of  potassium  at  one 
time  was  supposed  to  have  a  specific  action  on  syphilis  ; 
but  for  many  years  it  has  been  regarded  not  as  a  specific, 
but  as  a  valuable  adjunct  to  mercury.  In  the  early  stages 
of  the  disease  it  is  of  little  value,  its  therapeutic  efficiency 
increasing  in  direct  ratio  with  the  age  of  the  disease. 
It  acts  by  promoting  fatty  degeneration  and  absorption 
of  the  imperfectly  organised  exudates. 

As  a  rule,  iodide  of  potassium  is  unnecessary  in  the 
early  stages,  except  to  relieve  nocturnal  headaches  and 
periosteal  pains  generally.  In  such  cases  it  is  most  suc- 
cessful, given  in  5-grain  doses  three  times  a  day. 

In  the  later  stages  iodide  of  potassium,  either  given 
alone  after  a  thorough  course  of  mercury,  or  in  combination 
with   the   latter,   produces   results   which    are    sometimes 


176   SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

marvellous.  On  the  other  hand,  when  given  in  an  un- 
scientific manner  the  iodides  lead  to  grave  consequences. 
They  act  on  the  system  as  depressants,  lowering  it  to 
such  an  extent  that  it  is  left  an  easy  prey  to  the  further 
ravages  of  syphilis.  At  other  times  iodism  is  produced, 
represented  by  gastro-intestinal  irritation,  coryza,  pustular 
and  other  forms  of  skin  eruptions,  various  forms  of  neuritis, 
and  acute  oedema  of  the  larynx. 

In  ordinary  doses  most  patients  will  exhibit  no  symptoms 
whatever  from  the  use  of  the  iodides.  A  small  propor- 
tion may  suffer  from  a  coppery  taste  in  the  mouth,  coryza, 
and  perhaps  some  gastro-intestinal  catarrh.  A  still  smaller 
proportion  may  be  entirely  intolerant  of  iodide  of  potas- 
sium, and  will  suffer  from  swelling  of  the  mucous  mem- 
branes, especially  of  the  larynx  and  pharynx. 

Rules  for  giving  Iodide  of  Potassium. 

1.  The  drug  ought  to  be  given  well  diluted. 

2.  Excipients  facilitate  absorption. 

3.  It  should  be  given  about  an  hour  after  meals. 

4.  It  should  be  given  in  intermittent  courses  of  in- 
creasing doses,  never  for  longer  than  ten  days  at  a  time, 
after  which  there  should  be  a  week's  interval  before  it  is 
resumed. 

Dosage. — In  the  early  stages,  if  required,  the  average 
dose  is  gr.  v  three  times  a  day  ;  in  the  later  stages  gr.  x 
three  times  a  day,  increasing  up  to  gr.  xxx  three  times 
a  day ;  so  that  by  the  end  of  a  course  of  ten  or  fourteen 
days  the  patient  will  be  taking  5  ij  per  day :  as  much  as 
3  ij  three  times  a  day  may  be  found  necessary  in  some 
cases. 


ARYLARSONATE  AND   OTHER  METHODS  177 

Manner  of  Giving  Iodides. — They  may  be  given  in 
the  form  of  a  saturated  solution,  one  drop  of  which  re- 
presents approximately  gr.  j  of  iodide  of  potassium  : 

&  Iodide  of  potassium 5V 

Aquas  ad 5  J 

Dose  :  17\  v  to  V\  x  in  a  glass  of  milk  and  water  three  times  a  day. 

If  this  disagrees,  5  to  10  grains  of  pepsin  may  be 
added. 

The  great  thing  to  remember  in  giving  iodide  of 
potassium  internally,  is  to  give  it  well  diluted.  It  can 
be  taken  in  milk,  beer,  wine,  or  in  any  liquid. 

The  drug  can  be  given  by  enema  when  necessary. 
When  thus  administered  the  intestine  should  first  be 
evacuated  by  a  simple  enema.  Then  an  enema  of  iodide 
of  potassium,  gr.  xxx  to  gr.  xl  dissolved  in  3  ij  of  water 
with  a  few  drops  of  laudanum,  may  be  given. 

Hypodermic  Injection. — Hypodermic  injection  of  potas- 
sium iodide  is  sometimes  resorted  to.  This  mode  cannot 
be  recommended  owing  to  the  frequent  occurrence  of 
abscesses  and  sloughing. 

lodipin. — Iodipin  is  a  combination  of  iodine  and  sesame 
oil,  and  is  prepared  in  two  strengths,  i.e.  10  °/Q  and  20  °/Q, 
the  former  for  internal  medication,  the  latter  for  injection 
purposes.  Although  the  desired  therapeutic  effects  can 
be  brought  about  by  giving  it  internally,  this  manner  is 
not  recommended,  as  it  is  apt  to  bring  on  dyspepsia. 
Given  hypodermically  and  intramuscularly,  the  dose  is  : 
from  c.c.  x  to  c.c.  xx  for  ten  consecutive  days.  The 
syringe  should  be  capable  of  holding  at  least  10  c.c. 
The  needle  should  be  2\  in.  long,  and  have  a  large  bore. 

12 


178    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Injections  are  best  given  in  the  loose  tissues  of  the 
loins.  Iodipin  is  a  viscid  fluid,  and  requires  heating  to 
at  least  body  temperature  to  bring  it  to  the  proper 
consistence  for  injection  purposes.  The  advantages 
claimed  for  iodipin  over  iodide  of  potassium  are  that  it 
is  more  slowly  absorbed  and  excreted  than  the  latter  ; 
that  it  is  non-depressent,  and  does  not  interfere  with  the 
digestion.  I  have  used  iodipin  very  extensively,  and  can 
recommend  it  as  a  substitute  for  potassium  iodide  in  all 
cases  where  the  latter  is  inadmissible.  It  has  one  ob- 
jection— i.e.  the  large  bulk  it  is  necessary  to  inject  at  a 
sitting. 

Iodism. — The  treatment  of  iodism  will  depend  on  the 
severity  or  otherwise  of  the  symptoms.  When  these  are 
mild,  and  it  is  important  to  continue  the  drug,  the  iodide 
may  be  given  in  increased  doses ;  but  when  severe,  dis- 
continuance of  the  drug  is  imperative. 

The  character  of  the  iodide  rash  is  important : 

i.  Rapidity  of  invasion. 

2.  Begins  as  a  vesicle,  and  runs  speedily  through  a 
pustular  stage. 

3.  The  margins  are  inflamed  with  a  bright  red  areola. 

4.  The  base  is  soft. 

5.  The  suppression  of  the  drug  causes  the  disappearance 
of  the  rash. 


CHAPTER   XV 

MODERN   AIDS   IN  THE   DIAGNOSIS    OF 
SYPHILIS 

SCHAUDINN  in    1905   discovered    the    Spirochceta  pallida, 

and  from  various  experiments  was  led  to  believe  that  this 

spirochete  was  the  true  cause  of  syphilis — a  belief  soon 

to  be  fully  confirmed  by  some  of  the  greatest  pathologists 

of  the   day,    notably    Metchnikoff,    Levaditi,    Roux    and 

Koch,  and  to-day  it  is  the  generally  accepted  fact. 

Since   a   positive   diagnosis    can    only   be   obtained  by 

finding   the   Spirochceta   pallida,   the   importance   of    this 

discovery   of  Schaudinn  can  easily  be   imagined.      It   is 

of  greater  value  in  the  primary  stage  of  syphilis  than  at 

any  other.     In  no  stage  of  the   disease   is    diagnosis   so 

important.       Seen    early,   some   chancres    defy   the   most 

experienced  in  coming  to  a  conclusion  as  to  their   real 

nature,  with  the  result  that  one  of  two  courses  is  usually 

adopted — either  the  patient  is  given  mercury  with  a  three 

or   four   years'   treatment   to    look    forward    to,   and   the 

constant  thought  of  suffering    from    a    disease    of  which 

he  may  be  entirely  innocent,  or  he  is  given  no  treatment 

until  the  whole   system    is  infected    and  secondaries    are 

obvious.     Thus  the  most  valuable  time  for  grappling  with 

179 


180   SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

the  disease  is  lost,  for  it  is  an  undoubted  fact  that  the 
earlier  treatment  is  begun,  and  the  more  vigorously  it 
is  carried  out  in  the  primary  stage,  so  much  the  sooner 
may  a  cure  be  looked  for  and  further  developments 
prevented. 

To  demonstrate  the  Spirochceta  pallida  the  specimen 
should  be  examined  by  the  "dark  ground  illumination." 
This  latter  is  obtained  by  using  a  condenser,  which  allows 
no  rays  of  light  to  reach  the  eye  except  those  reflected 
by  certain  objects,  such  as  the  Spirochceta  pallida,  which 
appears  as  a  delicate,  attenuated,  brightly  illuminated 
silvery  corkscrew  standing  out  in  beautiful  contrast  on 
a  dark  or  intensely  black  field.  The  necessary  apparatus 
for  the  "  dark  ground  illumination "  can  be  adapted  to 
any  microscope  at  a  comparatively  small  cost,  and  the 
technique  for  setting  up  the  specimen  is  extremely  simple. 
By  its  means  a  diagnosis  can  be  established  in  the  case 
of  an  untreated  syphilitic  sore  in  a  very  few  minutes. 

It  is  of  course  necessary  for  the  observer  to  familiarise 
himself  with  the  appearances  of  the  various  spirochaetes 
under  this  method  of  examination,  but  when  the 
characteristic  appearance  of  the  Spirochceta  pallida  has 
been  once  mentally  fixed,  no  mistake  should  occur.  In 
lesions  of  the  genital  organs  the  spirochaetes  which  are 
likely  to  cause  confusion  at  first  are  the  finer  forms  of 
Spirochceta  refringens,  amongst  which,  without  com- 
mitting oneself  to  any  definite  opinion  as  regards  their 
relationship  to  the  form  originally  named  by  Schaudinn 
and  Hoffman  as  6".  refringens,  may  be  mentioned  6". 
balanitidis  and  the  spirochaetes  of  ulcerating  cancers  and 


MODERN  AIDS  IN  THE  DIAGNOSIS  OF  SYPHILIS    181 

papillomata.  In  general  these  differ  from  the  6".  pallida 
by  their  greater  thickness,  irregularity  of  undulations 
and  the  wider  spacing  of  the  latter,  while  they  are  to  be 
found  on  the  surface  rather  than  in  the  depths  of  the 
sore,  and  in  the  ulcerated  area  rather  than  the  indurated 
margin. 

The  beginner  at  this  method  of  examination  is  strongly 
urged  to  make  himself  familiar — by  taking  specimens  from 
the  surface  of  syphilitic  sores,  from  the  deeper  layers  of 
epithelium  at  the  indurated  margin,  from  the  secretion  of 
cases  of  balanitis,  and  from  other  than  syphilitic  lesions — 
with  the  appearance  of  the  various  spirochetes  found  in 
these  conditions.  He  will  find  half  an  hour's  work  in 
this  direction  of  more  value  than  pages  of  description. 

Burri's  Method1  consists  of  demonstrating  the 
Spirochceta  pallida  by  means  of  Chinese  ink.  A  platinum 
loopful  of  secretion  from  a  sore  is  placed  upon  a  slide, 
surrounded  by  seven  or  eight  loopfuls  of  distilled  water 
and  the  same  quantity  of  a  solution  of  Chinese  ink. 
The  whole  is  mixed  and  spread  out  upon  a  slide,  or  a 
blood  film  is  made,  allowed  to  dry,  and  examined  with  an 
oil-immersion  lens.  The  ink  produces  a  dark  background, 
and  the  objects  under  examination  stand  out  white. 

Giemsa's  Stain.  —  At  one  time  it  was  believed 
that,  whereas  all  other  spirochetes  stained  blue  with 
Giemsa's  stain,  the  Spirochceta  pallida  stained  pink  ;  but 
now  it  is  known  that  the  latter  sometimes  stains  blue, 
so  that  staining  is  not  really  a  very  strong  point. 

1  The  Journal  of  Clinical  Research^  May  1910,  p.  59,  has  a  note  on 
this  method. — [Ed.] 


1 82    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Excision  of  Chancres. — Neisser's  experiments  on  the 
infectivity  of  organs  of  syphilised  monkeys  at  different 
periods  after  inoculation,  show  that  by  the  time  the 
chancre  has  appeared  (in  fact  long  before),  the  spirochete 
has  already  established  itself  in  the  hemopoietic  organs 
and  blood,  so  that  excision  of  the  chancre  is  theoretically 
not  sound.     Levaditi  and  Koch  condemn  it. 

The  Spirochaeta  Pallida. — That  the  Spirochceta  pallida 
is  the  true  organism  of  syphilis  has  been  established  beyond 
a  doubt  from  the  following  : 

It  is  found  only  in  syphilitic  lesions. 

It  has  been  found  in  the  blood  of  syphilitics. 

It  has  been  found  in  the  blood  and  viscera  of  syphilitic 
infants. 

Metchnikoff  and  Roux  found  it  in  lesions  in  monkeys 
caused  by  inoculation  from  syphilitic  men  and  monkeys. 

Wassermann's  Serum  Reaction  Test.1 — Of  recent 
advances  in  medicine  none  can  claim  to  be  of  so  much 
importance  as  the  serum  diagnosis  of  syphilis,  a  test  based 
on  what  is  known  as  the  Bordet-Gengou  reaction.  The 
latter  is  a  binding  of  the  complement  which  takes  place 
when  an  antigen  meets  with  its  homologous  inactive 
immune  serum,  erythrocytes  and  hemolytic  serum  (which 
has  been  inactivated  in  order  to  rob  it  of  its  complement). 
No  hemolysis  can  occur  if  the  complement  has  become 
bound,  because  the  hemolysin  has  no  free  complement. 
Founded  on  this,  Wassermann  discovered  that  a  positive 

1  A  useful  article  on  "  The  Serum  of  Diagnosis  of  Syphilis  "  will  be 
found  in  The  Practitioner,  September  1909  [Ed.],  also  see  E.  Merck's 
Annual  Report,  Vol.  XXII. 


MODERN  AIDS  IN  THE  DIAGNOSIS  OF  SYPHILIS    183 

reaction  could  be  obtained  by  the  bringing  together  of 
bacterial  extracts  and  immune  serum,  and  later  on  proved 
that  extracts  of  organs  behaved  as  the  antigen,  and  that  in 
the  serum  of  apes,  which  had  been  treated  with  syphilitic 
extract,  substances  appeared  which  brought  about  fixation 
of  the  complement.  Finally  he  found  the  same  substances 
in  serum  of  human  syphilitics. 

In  Wassermann's  test  the  antigen  is  obtained  from  the 
liver  or  spleen  of  an  hereditary  syphilitic  infant  ;  the  anti- 
serum from  the  blood  of  the  patient ;  the  complement  from 
guinea-pig  serum ;  the  erythrocytes  from  sheep's  blood ; 
and  the  hemolytic  serum  from  an  immunised  rabbit. 

The  technique  of  Wassermann's  test  is  certainly  very 
intricate,  and  can  only  be  satisfactorily  carried  out  in  a 
well-equipped  laboratory  and  by  an  expert,  and,  as  at 
present  instituted,  can  never  come  within  the  range  of  the 
general  practitioner.  Of  late  years  many  workers  have 
endeavoured  to  modify  and  simplify  the  test,  but  have 
not  succeeded,  and  at  the  present  moment  Wassermann's 
original  method  still  holds  its  ground  as  the  most  approved 
and  most  reliable  of  all. 

The  value  of  Wassermann's  reaction  varies  according  to 
the  stage  of  the  disease.  In  the  primary  stage  a  positive 
result  is  not  obtained  in  more  than  40  per  cent,  of  cases. 
In  the  secondary  stage  a  positive  reaction  is  obtained 
in  85  per  cent,  of  all  cases,  whether  showing  secondary 
manifestations  or  not,  and  where  the  patient  is  under- 
going treatment.  When  there  are  secondary  signs  present, 
such  as  rash,  and  where  the  patient  has  not  yet  had  any 
mercury,  97  per  cent,  give  a  positive  Wassermann. 


1 84    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

Treatment,  of  course,  influences  the  results  of  Wasser- 
mann's test.  Directly  after  a  course  or  courses  of  inter- 
mittent treatment  the  reaction  is  usually  negative,  but 
when  the  mercury  becomes  eliminated  the  reaction  result- 
ing is  positive.  The  greater  the  number  of  courses  the 
more  likelihood  there  is  of  a  negative  result,  which  in 
time  may  become  permanent ;  and  herein  lies  a  most 
important  point  in  connection  with  the  Wassermann  test. 
Should  a  case  which  has  undergone  a  thorough  treat- 
ment give  a  negative  reaction  three,  six,  or  nine  months 
after  the  cessation  of  all  treatment,  is  it  then  justifiable 
to  give  an  opinion  that  a  cure  has  been  established  ?  This 
would  indeed  be  a  great  advance ;  but  at  present  the 
reaction  is  not  certain  enough  to  justify  such  an  opinion  ; 
time  and  further  experience  of  the  test  can  alone  tell  us. 

Two  facts  which  Wassermann's  test  has  taught  us  are  : 
the  enormous  benefit  which  arises  from  an  early  and 
vigorous  treatment ;  and  the  advantage  of  injections  and 
inunction  over  the  oral  administration  of  mercury. 

Whatever  time  may  tell  us  as  to  the  value  of  Wassermann's 
test  in  enabling  a  definite  opinion  to  be  given  as  to  cure 
or  not,  there  can  be  no  doubt  as  to  its  present-day  value 
to  the  clinician,  in  not  only  enabling  him  to  diagnose 
syphilis,  but  also  to  differentiate  between  it  and  other 
diseases. 

i.  Take  a  very  common  instance — that  of  a  patient  who 
gives  a  history  of  a  sore  which  appeared  a  few  days  after 
connection,  and  disappeared  within  ten  days  to  a  fortnight. 
No  notice  is  taken  at  the  time,  but  some  months  later 
a  few  spots  appear  on  the  body,  and  a  medical  opinion 


MODERN  AIDS  IN  THE  DIAGNOSIS  OF  SYPHILIS    185 

is  sought,  but  no  definite  conclusion  can  be  arrived  at. 
With  such  a  history  and  a  "  positive  "  Wassermann  there 
cannot  be  any  doubt  as  to  the  nature  of  the  disease,  and 
treatment  should  be  commenced  forthwith. 

2.  Differential  diagnoses  between  various  ulcers  and 
syphilitic  ones. 

3.  Gummatous  periostitis  and  sarcoma. 

4.  Gummata  of  the  testes,  tubercle,  and  new  growth. 

5.  Gumma  and  malignant  growth  of  the  liver. 

6.  Syphilitic  ulceration  of  the  tongue  and  epithelioma. 
The  author  had  a  case  which  was  under  orders  to  have  ex- 
cision of  the  tongue  for  cancer.  There  was  no  evidence  of 
acquired  syphilis,  but  slight  of  hereditary  disease.  Wasser- 
mann's  test  gave  an  undoubted  positive  reaction.  The 
patient  was  put  on  atoxylate  of  mercury  injections,  which 
cleared  up  the  local  affection  at  once. 

7.  Between  general  paralysis  of  the  insane  and  other 
cerebral    affections,    100   per    cent,   of   cases    of    genera 
paralysis  give  a  positive  reaction. 

8.  Tabes,  in  which  70  per  cent,  of  the  cases   give  a 
positive  reaction. 

9.  In  cases  of  repeated  abortions. 

10.  Between  cases  of  hereditary  syphilis  and  tubercle. 

11.  Syphilitic  affections  of  the  eye,  and  those  due  to 
some  other  cause. 

Some  two  years  ago  a  case  was  sent  to  the  author, 
the  patient  a  male,  aged  fifty-five,  who  had  suffered  for 
thirty  years  from  rheumatic  arthritis  and  periodic  attacks 
of  what  was  considered  rheumatic  iritis.  The  oculist 
who   sent   the   case   wanted   to    see    how    these    attacks 


186    SYPHILIS:    ITS  DIAGNOSIS  AND   TREATMENT 

behaved  under  metallic  mercurial  injections.  Although 
there  was  no  history  nor  sign  whatsoever  of  either  acquired 
or  hereditary  syphilis,  the  patient's  blood  when  sub- 
jected to  Wassermann's  test  gave  an  undoubted  positive 
result.  The  case  was  treated  accordingly,  since  which 
time  there  has  been  no  recurrence  of  iritis,  and  now  the 
reaction  has  been  negative  for  the  last  four  months. 

Conclusion. — The  value  of  these  two  discoveries — i.e. 
of  the  Spirochczta  pallida  by  Schaudinn,  and  the  serum 
reaction  test  by  Wassermann — have  opened  up  a  new  era 
in  the  clinical  study  and  treatment  of  syphilis.  Their 
importance  cannot  be  exaggerated.  The  former  enables 
us  to  give  a  definite  opinion  as  to  the  character  of 
the  primary  lesion,  which  in  itself  is  a  tremendous  ad- 
vantage ;  whilst  Wassermann's  reaction  test  has  been 
proved  by  experience  in  several  thousands  of  cases  all 
over  the  world  to  be  one  which  is  practically  specific 
for  syphilis.  It  is  therefore  an  addition  to  the  diagnostic 
armament  of  the  very  highest  value.  Apart  from  its 
value  as  an  aid  to  diagnosis  in  obscure  cases,  I  believe 
there  is  reason  to  hope  that  by  it  we  may  gain  some 
knowledge  as  to  the  progress  which  treatment  is  making 
against  the  disease.  Though  the  reaction  is  of  too  recent 
date  to  enable  one  to  make  any  definite  statement  on 
this  question,  it  seems  to  be  undoubted  that  efficient 
treatment  does  tend  to  convert  a  "  positive  "  reaction  into 
a  "  negative  "  one  ;  and  in  the  great  majority  of  cases  the 
occurrence  of  a  negative  reaction  in  cases  of  syphilis  after 
efficient  treatment  appears  to  be  the  more  frequent  as 
the  clinical  signs  indicate  a  return  to  health.     Whether  it 


MODERN  AIDS  IN  THE  DIAGNOSIS  OF  SYPHILIS    187 

will  eventually  be  possible  to  determine  from  a  succession 
of  negative  reactions  that  treatment  has  effected  its 
purpose  and  can  be  discontinued  is  a  question  which 
can  only  be  determined  after  the  lapse  of  many  years,  when 
the  history  of  the  cases  whose  blood  has  already  been 
tested  and  found  to  be  persistently  "  negative "  has  been 
followed  out  to  the  end. 


INDEX 


{Authorities  in  Italics) 


>,n+V,.   A      a  + 


I     Arteritis    rerphral    Rc\ 


ERRATA   TO   INDEX 
Omit — 

Arsonates,  170 
Glossitis,  sclerotic,  173 
Leucoplakia,  172 

Add— 

Arseno-phenyl-glycin,  171 
Dioxy-diamido-arseno-benzol,  173 
"  Ehrlich-Hata-No.  606,"  172 
Sodium  acetyl-phenyl-arsonate,  171 
Wasseiman's  Reaction,  172-174B 


Antigen,  102 

mmucuue  ui  uiciuuiy,  no 

Antipyrin,   103 

Black  wash,  42,  60 

Antiquity  of  syphilis,  4 

Blood,  changes  caused  in,  bymercury, 

Anti-serum,  183 

156 

Anti-syphilitic  serum,  14 

Blue  pill,  117 

Anus,  chancres  of,  25 

Boerhaave,   130 

Aortic  regurgitation,  86 

Bones,  secondary  affections  of,  66 

Aphasia,   66 

—  tertiary  affections  of,  83 

Aphonia,  78 

Borax,  58 

Argyll- Robertson  pupil,  96 

99,  106 

Bordet-Gengou  reaction,  182 

Aristol,  42 

Boric  acid,  42,  59,  60 

Arsacetin,  171 

Breast,  chancre  of,  36 

Arsenic,   1 1 1 

Bromides,   109 

Arsonates,  170 

Buccal  hygiene,  131,  137 

Arsonic  acid,  170 

—  tolerance,  sex  differences,  121 

Arterial  system,    tertiary 

affections 

Burri's  method  (Chinese  ink),  181 

of,  86 

Bursas,  secondary  affections  of,   67 

Arteritis,  86 

—  tertiary  affections  of,  82 

INDEX 


(Authorities  in  Italics) 


Aachen,  method  at,   131,   132 

—  water,  composition,  133 

Acid,  chromic,  44,  58,  62,  76,  114 

— nitrate  of  mercurj',  60 

Acne,    51 

Aix-la-Chapelle,  see  Aachen. 

Albuminuria,  49,  66,  80,  168 

Alcohol,  rules  during  inunction,  137 

Alimentary  system,  tertiary  affec- 
tions of,   72 

Alopecia,  60 

Alphyl,    170 

Ambrosoli,  of  Milan,  142 

American  origin  of  syphilis,  5 

Ammonium   chloride,    150 

Amyloid  degeneration  of  kidne}7,  81 

of  liver,  79 

Anasmia,  56 

Analgesia,   159 

Aneurysm,  86,   89 

Angina  pectoris,   49 

Aniline,  i7r 

Ankylosis,  84 

Annular  chancre,  19 

Antifebrin,   103 

Antigen,  182 

Antipyrin,   r03 

Antiquity  of  syphilis,  4 

Anti-serum,  183 

Anti-syphilitic  serum,  14 

Anus,  chancres  of,  25 

Aortic  regurgitation,  86 

Aphasia,   66 

Aphonia,  78 

Argyll- Robertson  pupil,  96,  99,  106 

Aristol,  42 

Arsacetin,  171 

Arsenic,   in 

Arsonates,   170 

Arsonic  acid,  170 

Arterial  system,  tertiary  affections 
of,  86 

Arteritis,  86 


Arteritis,  cerebral,  89 
Arthritis,   gummatous,  84 

—  secondary,   67 

—  tertiary,  84 
Arylarsonates,  75,    109,   no 

—  treatment  by,  170 
Ascites,  80 
Atheroma,  88 

—  of  aorta,  86 
Atoxyl,  170,  172 
Atoxylate  of  mercury,  173,  185 
Atropine,  63 
Auto-inoculation,  30 

Auxiliary  means  of  treatment,    175 
"Ayurvedas,"  2 

/3-cocaine,  160 

Baccelli,  169 

Bacillus  paralyticans,  98 

Bacteriology  of  syphilis,  n 

Balzer,  144 

Baron  Larrey's  syrup,  119 

Baths,  hot-air,  114,  175 

—  Turkish,  114,  175 
Biett,  120 

Biniodide  of  mercury,  118 

Black  wash,  42,  60 

Blood,  changes  caused  in,  by  mercury, 

156 
Blue  pill,  117 
Boerhaave,   130 
Bones,  secondary  affections  of,  66 

—  tertiary  affections  of,  83 
Borax,  58 

Bordet-Gengou  reaction,  182 
Boric  acid,  42,  59,  60 
Breast,  chancre  of,  36 
Bromides,   109 

Buccal  hygiene,  131,  137 

—  tolerance,  sex  differences,  121 
Burri's  method  (Chinese  ink),  181 
Bursas,  secondary  affections  of,   67 

—  tertiary  affections  of,  82 


189 


190 


INDEX 


Cachexia,   syphilitic,   47 
Calomel,  dry  dressing,  43 

—  dusting  powder,  60 

—  injections,  75,  95,  103,  144,  156, 
162 

formula  for,  162 

pain  after,  160 

—  ointment  (Metchnikoff),  43 
Camphoric  acid,  160 
Cancer  of  lip,  32 

—  of  tongue,  74 
Carbolic  acid,  43,  58,  60, 

—  lotion,  42 
Castellani,  31 
Cautery,  actual,  44 
Central  America,  1,  4 
Cephalalgia,  64 

Cerebral  syphilis,  statistics,  91 
Cerebro-spinal  fluid,  leucocytosis  of, 
94,  96 

—  syphilis,  94 
Chancre,  description  of,  17 

—  indurated,  10 

—  prognosis  of,  37 

—  seats  of,  21 
anus,  25 

base  of  penis,  23 

breast,   36 

concealed,  24 

extragenital,    32 

eye,  34 

face,  35 

finger,  35 

general  integument,  36 

genital,  22 

groin,  25 

lip,  32 

preputial,  24 

scrotum,   2  3 

sub-preputial,  24 

tongue,  33 

tonsil,  34 

urethra,  22 

urinary  meatus,  22 

—  structure  of,  18 

—  treatment  of,  40 

—  varieties  of,  19 

annular,  19 

ecthymatous,    19 

dry  papule,  19 

false  relapsing,  21 

mixed,  20 

phagedenic,    43 

recurring,  20 

silvery  spot,  19 

true  relapsing,  21 

vaccination,  36 

Chancroid  inflammation,  26 
Chancrous  erosion,   18 
Charcoal  poultices,  44 
Charcot's  gait,  87 

—  joint,  102,   107 
Charles  (Physiology),   159 

—  V.,  Emperor,  6 


Charles  VIII.  of  France,  4,  6 
Chimpanzee,  inoculation  of,  14 
Chinese  ink  method,  181 
—  knowledge  of  syphilis,  2 
Chlorate  of  potash,  58,  113 
Chomel's  pills,  119 
Chorea,  90 
Choroiditis,   63 

Chromic  acid,  44,  58,  62,  76,  114 
Circinate  syphilide,  54 
Circulatory    system,    tertiary    affec- 
tions of,  86 
Cocain  hydrochlorat.,  150,  160 
Collins,  97 

Columbus,  sailors  of,  4 
Concealed  chancres,  24 
Condylomata,  59 
Conjunctival  chancre,   34 
Copper,  sulphate  of,  113,  114 
Coryza,    176 
Creo-camph.,  161,  162 
Creosote,  160 
Cyclitis,  63 
Cyto-diagnosis,  103 
Cytoryctes  luis,    12 

Dactylitis  syphilitica,  85 
Dark-ground  illumination,  180 
De  Lisle,  12 

Depression,  mental,  66 
Dermatitis  during  inunction,   139 

—  secondary,  49 

—  tertiary,  70 
Dermatol,  42 

Destruction  of  syphilitic  virus,  41 
Diagnosis,  differential,  28,  184 

—  of  chancre,  27 

—  modern  aids  to,  179 
Diarrhoea,    139 

Diaz  de  Isla,  5,  6 

Diet  during  inunction,  137 

Diffuse  paronychia,  61 

Digestive  organs,  action  of  mercury 

preparations  on,  121 
Dosage  of  mercury,  124 
Dose,      maximum       for      injection, 

166 
Dry  papule,  the,  19 
Ducrey,  8 

Dupuytren's  pills,  118,  124 
Fournier's  modification  of,  119, 

124 
Duration  of  treatment,  167 
Dystrophy  of  the  neurones,  96 

Eburnation  of  bony  tissue,  83 
Ecthymatous  chancre,  the,  19 
Eczema,  35 

Edinburgh,  syphilis  in,  7 
Ehrlich,  of  Frankfort,  171 
Embolism,  148 
Endarteritis  obliterans,  86 
Endoperiarteritis,  86 
Enema  of  potass,  iodid.,  177 


INDEX 


191 


England,    introduction    of    syphilis 

into,  6 
Epididymis,  secondary  affections  of,  68 
Epilepsy,  66,  108 
Epithelioma,  diagnosis  of,  32 
Erb,  97 
Eruptions,  secondary,  49 

—  tertiary,  70 
Erythema  of  larynx,  60 
Erythematous  syphilides,   51,   52 
Europhen,  42 

Exercise  during  inunction,  138 
Exostoses,  83 
External  method,  128 
Extragenital  chancres,   31 
Eye,  chancre  of,  34 

—  secondary  affections  of,  62 

Facial  chancre,  35 

False  relapsing  chancre,  21 

Ferguson,  William,  112 

Ferrier,  98 

"  Ficus,"  of  the  Romans,  2 

Finger,  chancre  of,  35 

—  tertiary  affections  of,  85 
Follicular  syphilides,  51,  52 
Fournier,  10,  90,  96,  97,  160 
Fournier's  modification    of    Dupuy- 

tren's  pill,  119,  124 
Fracture,  spontaneous,  107 
Fumigation,    169 

Gagniere,  156 

Gaseous     constituents     of     Aachen 

water,  133 
Gastro-intestinal  irritation,  176 
General  paralysis,  104 
Genital  chancre,  22 

—  organs,  mucous  patches  of,  59 
Giemsa's  stain,  12,  15,  181 
Girdle  pain,  93 

Glands,  enlargement  of,  46 
Glossitis,  gummatous,  73 

—  sclerosing,  73 

—  sclerotic,  173 

—  superficial,  72 
Glycerin,  144 
Gold,    in 
Gowers,  97,  99 

"  Grand  mal,"  108 
Grandiose  delusions,  105 
Grey  oil,  155 

—  powder,  118 
Groin,  chancre  of;  25 
Guaiacum,   in 
Guillain,  98 

Gumma,  structure  of,  9 
Gummata,  subcutaneous,  71 
Gummatous   syphilides,    71 
Gum-water,  144 
Guthrie,    112 

Hemolytic  serum,  183 
Haemoptysis,  79 


Hair,  affections  of  the,  60 

Haiti,  4,  5,  6 

Halliburton,   158 

Hallopeau,   170,    171 

Hardy,  143 

Headache,  nocturnal,  64,  175 

Hebrew  knowledge  of  syphilis,  3 

Hemiplegia,  early,  64 

—  syphilitic,  92 
Hepatitis,  79 
Hippocrates,   2 
Hoang-ti,  Emperor,  2 
Hoffmann,  13,  180 
Hoffmann's  pills,  119 
Hot-air  baths,  175 
Hot  compresses,  63 
Hot-water  baths,  175 
Hunter,  John,  7,  131 

experiment  of,  7 

Hutten,    Ulrich  van,   129 
Hydrocele,  85 

— ,  tapping,  86 
Hydrotherapy,    175 
Hydroxyl  group,  170 
Hygiene  of  mouth,  113,  137 
Hyperasmia  of  pharynx,  48 

—  of  tonsils,  48 

Hypodermic     injection     of     potass. 
iodid.,   177 

India,  syphilis  in,  2 
Indian    (W.),    source   of   syphilis,    5 
Indolent  paronychia,  61 
Indurated  chancre,  10 
Induration,   description   of,    17 
Injection,  intramuscular,  142 

—  sites  for,  165 

—  intravenous,  169 

Insoluble  salts,  injection  of,  154 
Internal  method,  remarks  on,  125 
Interstitial  nephritis,   81 
Intramuscular  method,    142 

advantages  of,   145 

disadvantages  of,  148 

points  in,  165 

stomatitis  after,  147 

success  of,  144 

technique  of,   164 

Intravenous  injection,  169 
Inunction,  cases  for,   141 

—  diet  during,  137 

—  disadvantages  of,  138 

—  exercise  during,  137 

—  mercurial,  95 

—  method,  128 

—  mode  of  action,  134 

—  ointments  for,  135 

Iodide  of  potassium,  72,  75,  175 

manner  of  giving,  177 

rash,  178 

Iodine,  solutions  of,  yj 
Iodipin,  72,   177 
Iodism,    176,    178 
Iodoform,  42,  59,  60,  62,  72 


ig-2 


INDEX 


Iridectomy,  63 
Irido- choroiditis,   63 
Iritis,  62 

James  IV.  of  Scotland,  7 
Japanese  knowledge  of  syphilis,  2 
Jaundice,  66,  80 

Joints,  secondary  affections  of  the, 
67 

—  tertiary  affections  of  the,  84 
Jullien,  143 

Kidney,  amyloid  disease  of,  81 

—  granular  contracted,  81 

—  secondary  affections  of,  49 

—  tertiary  affections  of,  81 
Knee-jerks,  100 

Koch,  171,  179,  182 
Kolliker,  143 

Labial  chancre,  32 

—  epithelioma,  33 
Lafay's  formula,  158 
Lambkin's  original  formula,  158 
Lancereaux,    2 

Lang,  of  Vienna,  154,  157 
Larrey's  syrup,  119 
Laryngitis,  early,  60 
Larynx,  affections  of,  60 

—  erythema  of,  60 

—  oedema  of,  176 

—  tertiary  affections  of,  78 
Las  Casas,  5,  6 

Lee,  Henry,  169 

Leeches,  63 

Leishman,   161 

Lenticular  syphilides,  51,  53 

Lepra,  syphilitic,  54 

Leprosy,  Biblical  account  of,  3 

Leucocytosis  of  cerebrospinal  fluid, 

94,  96 
Leucoderma,  56 
Leucoplakia,  58,  172 
Levaditi,  9,  14,  179,  182 
Lichen,  50 
Liegois,  143 
Lightning  pains,  99 
Lips,  chancre  of,  32 

—  tertiary  lesions  of,  72 
Liver,  congestion  of,  66 

—  tertiary  affections  of,  79 
Locomotor  ataxia,   96 

Lungs,  tertiary  affections  of,  78 
Lupus,  differential  diagnosis,  77 
Lustgarten's   bacillus,    12 
Lymphangitis,  inflammatory,  39 

—  specific,  39 

Lympho-angiotic  theory  of  tabes,  98 
Lymphocytosis,  97 

Magrath,  98 
"  Mai  francais,"  128 
Malaria,  168 
Maries,  98 


Melting-point    of    mercurial    cream, 

161 
Meningitis,  91 

—  spinal,  93 
Meningo-myelitis,  93 
Mental  depression,  66 
Mercurial  cream,  158 

—  ointment,  46,  72 

—  plaster,  86 

—  soaps,  135 
Mercury,  in 

—  acetate  of,  150 

—  acid  nitrate  of,  60 

—  alaniate  of,  150 

—  and  ammonium,  double  chloride 
of,  149 

—  atoxylate  of,  173,  185 

—  benzoate  of,  150 

—  bichloride,  61-3,  152 

—  biniodide,  118,  150 
oil,  151 

—  chloro-  albumin  ate  of,  150 

—  contra-indications,    168 

—  cyanide  of,  150 

—  dosage  of,   124 

—  ingestion  method,  115 

—  intramuscular  method,  142 

—  lactate  of,  150 

—  metallic,    154 

advantages  of,   155 

disadvantages  of,    161 

—  methods  of  administering,  114 

—  oleate  of,  43 

—  peptonate  of,  149,  151 

—  perchloride,  118:  see  bichloride 

—  preparations  of,  157 

—  proto-iodide,   119 

—  salicylate,  118,  154,  156,  165 

—  sozoiodolate  of,   150,   151 

—  succinimate  of,    150,    152 

—  tannate  of,  118,  150 

—  urate  of,  150 

—  yellow  oxide  of,  144,  154 
Metchnikoff,  8,  14,  41,  no,  179,  182 

—  ointment,  41,  43,  no 
Methods,  ingestion,  115 

—  intramuscular,   142 

—  intravenous,  169 

—  inunction,   128 
Microbiology  of  syphilis,  11 
Migraine,  90 

Mixed  chancre,  20,  26 
Modern  aids  in  diagnosis,  179 
Moebius,  97 

Monkeys,  inoculation  of,  14 
Morphia,  160 

—  hypodermic,  68,  103 
Motor  paralysis,  64 
Mott,  96 

Mouth,  hygiene  of,  113,  137 

—  wash,  137 

Mucous  membranes,  secondary  affec- 
tions of,  57 

—  patches,  58 


INDEX 


193 


Mucous      membranes,     patches     of 

genital  organs,  59 
Muscles,  tertiary  diseases  of,  82 
Myelitis,   93 
Myositis,  chronic  infiltrative,   82 

—  gummatous  nodular,  82 

—  hyperasmic,  82 

Nails,  secondary  affections  of,  61 
"  Needle,  fear  of  the,"  160 
Needles,  164 
Neisser,   in,    172 

—  experiment,  181 
Nephritis,  49 

—  interstitial,  81 

Nervous    system,    secondary    affec- 
tions of,  64 

—  tertiary  affections  of,   90 
Neuralgia,  64 

Neuritis,  optic,  66 
Neurones,  dystrophy  of,  96 
Nitrate  of  silver,  58,  60 
Nitric  acid,  43,  44,  60,  62 
Nocturnal  headaches,  64,  175 
Nose,  syphilitic  affections  of,  59 

Ocular  chancre,  34 
Ointment,  mercurial,  46,  72 
Metchnikoff's,  41,  43,  no 

—  white  precipitate,  61 
Okamura,  2 

Oleate  of  mercury,  43 

Olein,  158 

Oleum  cinereum,  155,  157 

Olive  oil,  144 

Onychia,   61 

Opaline  patches,  57 

Optic  atrophy,  103 

—  neuritis,   66 
Orchitis,  68 
Osteoperiostitis,    83 
Osteotic  pains,  47 
Oviedo,  5,  6 

Pain  after  injection,  148,  152,   155, 

159 
Pains,  neuralgic,  47 

—  osteotic,  47 

—  periosteal,  175 

—  rheumatic,  48 

—  rheumatoid,  67 
Palate,  gumma  of,  76 
Palmitin,  158,  159 
Palpebral  chancre,  34 
Panarteritis,  86 
Panas,  151 

Papular  syphilides,  51,  53 
Paraffin,  liquid,  144 
Paralysis,  general,  104 

—  motor,  eye  and  face,  64 
Paraplegia,  92,  93 

—  early,  64 
Parasyphilis,   10,   96 
Parchment-like  sore,  18 


Parenchymatous  iritis,  62 

Parenga  (Yaws),   31 

Paronychia,  61 

Pasteur,  n 

Patellar  bursa?,  82 

Pathology  of  syphilis,  9 

Peninsular  War,  112,  128 

Penis,  chancres  of,  23 

Perforating  ulcer,  107 

Perhydrol  (Merck),   43,   58,  72,  76, 

77,  113,   114 
Peri- arteritis,  10,  86 
Perihepatitis,  79 
Periosteal  pains,  175 
Periostitis,  66 
Peroxide  of  hydrogen,  59,  76,  113 

lotion,  42 

"  Petit  Mai,"  108 
Phagedasnic  chancres,  43 
Pharynx,  hyperemia  of,  48 

—  tertiary  affections  of,   77 
Phenacetin,  103 

Pian  (Yaws),  31 
Pigmentary  syphilides,  56 

retiform,  56 

Plan  of  treatment,  166 

"  Plaques,"  48,  58 

Plastic  iritis,  62 

Platinum,  in 

Pleural  effusion,  66 

Plummer's  pill,  58 

Potassium,  chlorate  of,  58,  113 

—  iodide,  95,  103,  109,  in,  175 
rules  for,  176 

Prehistoric  existence  of  syphilis,  2,  3 
Prepuce,  chancres  of,  24 
Prescriptions,  76,  113,  117,  118,  150, 

151,  157,  158,  161,  162 
Profeta,  143 

Proto- iodide  of  mercury,  118,  119 
Psoriasis,  50 

—  of  the  tongue,  58 

Pupil,  Argyll- Robertson,  96,  99,  106 
Pustular  syphilides,  55 

Quaternary  syphilis,  96 
Quinine,  168 

Ravant,  94,  97 

Rectum,  tertiary  affections  of,  81 

Recurring  chancre,  20 

Relapsing  chancre,  21 

Resorcin,  60 

Retiform  pigmentary  syphilide,  56 

Retinitis,  63 

Reuter,  13 

Rheumatic  pains,  48 

Rheumatoid  pains,  67 

Ricord,  7 

Ricord's  pills,  120 

Fournier's  modification  of,  124 

Robertson,   Argyll-,    pupil,    96,    99, 

106 
Robertson,  Ford,  98 

13 


194 


INDEX 


Rochester  Row,  formulae  at,  135,  137 

Romberg's  sign,  100 

Roseolar  syphilides,  52 

Roux,  8,  14,  179,  182 

Rubbing,  mode  of,  136 

Rupia,  55 

Salicylate  of  mercury,  118,  165 
Salivation,   112,   129 
Salmon,    1J0 
Sarsaparilla,    in 
Sassafras,  in 
Scarenzio  of  Pavia,  142 
Schaudinn,  8,  12,  13,  179 
Scotland,  syphilis  in,  7 
Scrotum,  chancre  of,  23 
Secondary  period  affections,  45 

albuminuria,  49 

angina  pectoris,  49 

cachexia,  47 

eruptions,  49 

eye,  62 

glandular,  46 

hair,  60 

joint,  67 

laryngeal,  60 

mucous  patches,  59 

nerve,  64 

nose,  59 

onychia,  61 

orchitis,  68 

paronychia,  61 

periostitis,  66 

syphilides,  49 

tenosynovitis,  68 

tongue,   57 

tonsils,  48 

visceral,  66 
Sedillot's  pill,  117 
Seigel,  12 
Senarega,  6 

Serum,    anti-syphilitic,    14 
Sicard,  97 
Silver,  in 
Silvery  spot,  the,  19 
Sites  for  injection,  165 
Sleeping  sickness,   170 
Smirnoff,  143 
Soamin,  171 
Sodium  chloride,   151 

—  iodide,  151 

—  paraminophenylarsonate,  171 
Soft  chancre,  diagnosis  of,  28 
Soluble  salts,  injection  of,  152 
Spinal  cord,  tertiary  syphilis  of,  93 
Spirochseta  balantiditis,   180 

—  pallida,  8,  12,  14,  27,  70,  no,  180 
examination  for,  15 

—  refringens,  12,  180 
Spitza,  13 

Spleen,  tertiary  affections  of,  80 
Spondylitis,  syphilitic,   83 
Spontaneous  fracture,  107 
Squamous  syphilides,  51,  54 


Starch,  60 
Stark,  143 

Statistics,  cerebral  syphilis,  91 
Stearin,   158 
Stewart,  Purves,  98 
Stirling,   158 

Stomach,  tertiary  affections  of,  81 
Stomatitis,  112,  129 
Stricture  of  rectum,  81 
Sublimate,    118,    149,    {see  Mercury 
bichlor.) 

—  gastralgia,  121 

—  solution,  42 
Sub-preputial  chancres,  24 
Sulphur,  in 

Susrutas,  2 

Sycosis,  35 

"  Sykos  "  of  the  Greeks,  2 

Syme,  129 

Synovitis,    secondary,    68 

—  tertiary,  84 
Syphilides,  49 
Syphilis,  history  of,  1 

—  pathology  of,  9 

—  prehistoric,  3 
Syphilo-dermata,  49 
Syphilophobia,  147 

Tannate  of  mercury,  118 
Tattooing,  infection  by,   36 
Taylor,  19 

Technique  of  the  external  method, 
132 

—  of  the  intramuscular  method,  164 
Tendons,  secondary  affections  of,  68 

—  tertiary  diseases  of,  82 
Teno-synovitis,  68,  82 
Tertiary  affections : 

alimentary  system,  72 

arteries,  86 

bones,  83 

bursae,  82 

circulatory  system,  86 

fingers,  85 

joints,  84 

kidneys,  81 

larynx,  78 

lips,  72 

liver,   79 

lungs,  78 

muscles,  82 

nervous  system,  90 

palate,  76 

pharynx,  77 

rectum,  81 

skin,  70 

spinal  cord,  93 

spleen,  80 

stomach,  81 

tendons,  82 

testes,  85 

toes,  85 

tongue,  72 

trachea,  78 


INDEX 


195 


Tertiary  syphilis,  69 

Testicle,  secondary  affections  of,  68 

—  strapping,  86 

—  tertiary  affections  of,  85 
Thucydides,  2 

Tinea  circinata,  54 

Toes,  tertiary  affections  of,   85 

Tongue,  cancer  of,  74 

—  chancre  of,  33 

—  fissures  of,  75 

—  gummata  of,  74 

—  superficial  affections  of,   57 

—  tertiary  affections  of,  72 

—  ulcers  of,   75 
Tonsils,  chancre  of,   34 

—  hyperaemia  of,  48 
Torella,  Gaspard,  128 
Trachea,  tertiary  affections  of,  78 
Treatment,  duration  of,  167 

—  plan  of,  166 

—  Zittmann's,  169 
Treponema    pertenue,    31 
True  relapsing  chancre,  21 
Tubercle,  differential  diagnosis,  77 
Turkish  baths,  114,  175 

Uhlenhuth,  170 

Ulcerative  gummatous  syphilides,  71 


Ulcerative  paronychia,  61 
Ulcers  of  tongue,  75 
Unguentum  hydrarg.,  43 
—  G.P.,   135 
Urethra,  chancres  of,  22 
Urinary  meatus,  chancres  of,  22 

Vaccination  chancre,  36 
Van  Swieten's  liquor,  118,  124 
Vegetating  papules,    59 
Vesicular  syphilides,   51,   55 
Visceral  affections,  secondary,   66 
tertiary,  79 

Wallender's  bag,  114 

Ward,  Major,  170,  173 

Wassermann's  reaction,  103,   182 

Weigert,  12 

West  Indian  Islands,  1,  5 

Westphal's  sign,  100 

White  precipitate  ointment,  61 

Whitlow,  35 

Widal,  94,  97 

Yaws,  31 

Yellow  wash,  42,  60 

Zittmann's  treatment,  169 


Bailliire,  Tindall  &  Cox,  8  Henrietta  Street,  Covent  Garden. 


DUE  DATE       aetgstjt 

r  _  -~~.        APT    1    A   1QQ1) 

v£ir 

; 

QOf 

W 

*■»*    j    «rirt  i 

IAW   j 

1 

t     JAPi  4 

MS 

DK 

1  9  1994 

JAN  1  9  « 

«P 

1394 

Printed 
in  USA 

Lambkin 
Syphilis, 


RC201.2 

L17 

1911 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl  stx) 

RC  201.2  L17  1911  C.1 

Syphilis : 


2002059746 


